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Investigator II
Horizon Connect @ Wall BCBSNJCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in conducting fraud investigations, preparing legal documentation, and collaborating with law enforcement agencies. Proficient in health insurance operations and skilled in managing case tracking systems.
Highest-signal resume keywords
Fraud InvestigationHealth Insurance OperationsMS Office ProficiencyClaims ManagementLegal Testimony
About the role
Key responsibilities & impact- Conduct analytical and investigative activities related to claims, enrollment, accounting and other operations to detect, receive and review suspected fraud
- Prepare and document fraud cases, assembling evidence for potential prosecution or civil litigation
- Provide evidence and/or testify in cases where law enforcement agencies pursue prosecution
- Handle field investigation work and coordinate efforts with law enforcement state agencies and claims stakeholders
- Represent the Company in complex settlement negotiations with attorneys and other responsible parties
- Testify in legal proceedings as required in fraud cases
- Follow procedures and guidelines outlined in the latest Federal Employee Health Benefits (FEHB) Carrier Letter
- Investigate cases impacting the FEP line of business, including FEP eligibility investigations
- Update and track the FEP SIU Tracking System with case activity, subpoenas, financial information, audits, referrals, settlements and convictions
- Interface with the BCBSA FEP SIU Consultant
- Manage fraud hotline calls impacting the FEP program
Requirements
What you’ll need- High School Diploma/GED required
- Minimum 2 yrs claims, customer service or relevant law enforcement experience required
- ITS/Blue Card knowledge preferred
- Basic knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.)
- Basic knowledge of SIU health insurance operations
- Excellent verbal and written communication skills
- Ability to effectively handle confrontational situations
- Demonstrated ability in MS Office applications, in particular Excel and Access
- Strong organizational skills
- Travel as needed to support investigative activity within Company's service area
- Employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
Benefits
Comp & perks- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Fraud InvestigationClaims ManagementHealth Insurance OperationsSIU OperationsCase DocumentationEvidence PreparationField InvestigationSettlement NegotiationFEP SIU Tracking SystemITS/Blue Card Knowledge
Soft Skills
Verbal CommunicationWritten CommunicationOrganizational SkillsConflict ResolutionInterpersonal Skills
Tools & Technologies
MS ExcelMS AccessFEP SIU Tracking System
Industry Keywords
Federal Employee Health BenefitsFEP ProgramClaimsEnrollmentUnderwritingLaw Enforcement CoordinationFraud Hotline Management