Job description
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
Job Summary:
This position is accountable for analytical and investigative activities (external and internal) related to claims, enrollment, accounting and other operations to detect, receive and review suspected fraud and to complete cases with all information and analysis for resolution, as the manager and prior approved guidelines may direct.
- Prepares and documents fraud cases, assembling evidence for potential prosecution or civil litigation.
- Provides evidence and/or testifies in cases where law enforcement agencies pursue prosecution.
- Personally handles field investigation work; and coordinates efforts with law enforcement state agencies and claims stakeholders.
- Represents the Company in conducting complex and potentially multi-million dollar settlement negotiations with attorneys and/or other responsible parties (representing providers, enrolled groups and individual subscribers).
- Serves as Company's representative in testifying in legal proceedings as required in fraud cases.
- Additional personal and professional attributes that are critical to successful performance:
Education/Experience:
- Bachelor Degree preferred or equivalent work experience
- Minimum 2 yrs claims, customer service or relevant law enforcement experience required.
- ITS/Blue Card knowledge preferred
Knowledge:
- Requires basic knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.).
- Requires basic knowledge of SIU health insurance operations.
Skills and Abilities:
- Requires excellent verbal and written communication skills.
- Requires the ability to effectively handle confrontational situations.
- Requires demonstrated ability in MS Office applications, in particular Excel and Access.
- Requires strong organizational skills
Salary Range:
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
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Comprehensive health benefits (Medical/Dental/Vision)
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Retirement Plans
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Generous PTO
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Incentive Plans
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Wellness Programs
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Paid Volunteer Time Off
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Tuition Reimbursement
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
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