Investigator II

About the role

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.

Responsibilities

• 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.
• Follow established procedures and guidelines outlined in the latest Federal Employee Health Benefits (FEHB) Carrier Letter.
• Investigate cases that impact the FEP LOB, as well as handling all investigations regarding FEP eligibility.
• Updating and tracking the FEP SIU Tracking System (FSTS) with case activity, subpoenas, financial information, audits, referrals, settlements and convictions of cases impacting the FEP.
• Interfaces with the BCBSA FEP SIU Consultant.
• Manages all calls from the Fraud hotline that impact the FEP program.

Requirements

• High School Diploma/GED required.
• Minimum 2 years 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

• 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.

Travel

Travel as needed to support investigative activity within Company's service area.

Benefits

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement

Pay

Salary Range: $63,000 - $84,420. 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.