Supv, FEP Investigations

About the role

This position manages an SIU Team within the Special Investigations Unit, specifically for our Federal Employee Program. Supervises a team of investigators charged with detecting fraudulent activities by subscribers, providers, groups, and other parties.

Responsibilities

• Provide general supervision to investigators with their case management/prioritization and provide guidance regarding the most efficient and effective method of investigation appropriate for each individual case.
• Guide investigators in the preparation and documentation of fraud cases for referral to the appropriate agencies and for potential prosecution or civil litigation.
• Coordinates with SIU Manager or Director regarding approval of settlement terms related to health care fraud investigations.
• Establishes and maintains liaison with local state and federal law enforcement as well as regulatory agencies (e.g. DOBI, MFD).
• Serves as Company's representative in testifying in legal proceedings as required in fraud cases.
• Represents the Company in conducting settlement negotiations with attorneys and/or other responsible parties (representing providers, enrolled groups and individual subscribers).
• Provides litigation support to the Legal Division's Litigation team as well as outside counsel hired to pursue civil litigation on behalf of Horizon BCBSNJ.
• Provides subject matter expertise to all SIU staff and other areas of the company.
• Represents the SIU on cross-divisional standing or temporary committees (e.g. Payment Integrity, Provider Credentialing).
• Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.

Requirements

• BA in criminal justice, business, or related discipline.
• Minimum of 7+ years of experience in professional investigations involving economic or health insurance related matters or relevant field.
• 2-3 years experience managing staff (preferred).
• AHFI, CFE, CPC or other relevant professional certification (in lieu of certification, a Masters degree may be considered).
• Licensing in a medical field a plus.
• In-depth knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.).
• Working knowledge of NJ Criminal and Civil Law relative to health insurance fraud.
• Knowledge of applicable fraud statutes: local, state, federal.
• Working knowledge of investigative process.
• Demonstrated ability in MS Office applications, in particular Excel and Access.
• Ability to create and interpret databases.
• Must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.

Skills

• Excellent verbal and written communication skills.
• Ability to effectively handle and defuse confrontational situations.
• Strong organizational skills.
• Demonstrated ability to conduct interviews/interrogations.
• Excellent negotiation skills.
• Proven analytical and research skills.

Benefits

At Horizon, you'll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too.

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

Pay

Salary Range: $87,300 - $119,070. 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.