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Investigator III
| Company | Horizon NJ Health |
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| Location | Newark, NJ, USA |
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| Salary | $69500 – $93030 |
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| Type | Full-Time |
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| Degrees | Bachelor’s |
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| Experience Level | Senior |
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Requirements
- Bachelors Degree Required.
- 5 years prior professional investigations experience involving economic or health insurance related matters required.
- Requires in depth knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.).
- Requires excellent verbal and written communication skills.
- Requires the ability to effectively handle and defuse confrontational situations.
- Requires demonstrated ability in MS Office applications, in particular Excel and Access.
- Requires strong organizational skills.
- Requires demonstrated ability to conduct interviews/interrogations.
- Requires the ability to create and interpret databases using multiple software applications.
Responsibilities
- Accountable for analytical and investigative activities related to claims, enrollment, accounting and other operations to detect, receive and review suspected fraud.
- Conduct and resolve investigations and manage their case load with limited management/supervisor oversight.
- Detects fraudulent activities by subscribers, providers, groups, employees and other parties.
- Decides the most efficient and effective method of investigation appropriate for each individual case.
- 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.
- Serves as Company’s representative in testifying in legal proceedings as required in fraud cases.
- Up to date and Knowledgeable about all applicable fraud statutes; Local, state and federal to ensure duties and assignments are carried out within the requirement of applicable law and local office expectations.
Preferred Qualifications
- May consider individual with health insurance SIU related experience.
- Prefers licensing in medical field.
- Prefers working knowledge of NJ Criminal and Civil Law relative to health insurance fraud.
- Prefers working knowledge of investigative process.
