Investigator I

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years , we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

About the role

The incumbent will complete and take appropriate action in gathering, analyzing and interpreting requisite documentation to conduct investigations. The incumbent supports the investigators related to research and resolution of fraudulent activity. The Analyst is expected to utilize relevant systems and software to analyze exposure, provider, and claims data to make informed decisions. They will manage the Special Investigations Unit pended claims to ensure we are meeting SLAs and service standards associated with ASO accounts and Blue Card requirements.

What you'll do

• Ensure timely, accurate and efficient resolution of pended claims in NASCO and Business Process Management (BPM) tool.
• Serves as the primary contact for fraud claim inquiries, referrals received from representatives, Team Leaders, Supervisors, Managers and Directors.
• Serves as the primary contact for other Blues Plans on any claim inquiries related to fraud investigations.
• Performs research, documents, and tracks issues within Blue Card admin and/or BPM tool. Forwards issues to the appropriate team and tracks issues for resolution.
• Perform investigative activities on less complex case reviews. Responsible for performing investigative duties such as analyzing coding, preparing, documenting and assembling evidence for potential prosecution and civil litigation.
• Collects and submits information necessary for claim suspension entry via ClearQuest tickets. Updates claims suspension to ensure continuity of active claim suspensions.
• Creates/Maintains UCSW/NCompass alerts & alerts messaging with up to date handling instructions surrounding claim suspensions. Shares active claim suspension listing with Special Investigations Analytics team for financial reporting and claim savings tracking.
• Investigates calls received to the Fraud Hotline. Gathers information related to the hotline call which includes member and provider outreach, request medical records, and claim review.
• Follows established procedures, guidelines and research utilizing multiple systems and tools. Share systems/tool knowledge with Investigative and/or PPR staff surrounding but not limited to: Nasco, BPM, FileNet, etc.
• Analyze and review confidential and highly sensitive investigative material/documents concerning employees, subscribers, providers and groups.
• Provides assistance in preparation of claims and/or UCSW/NCompass inventory reports. Assist as needed in reporting such as the daily aging report and process automation reports, for the investigations team and PPR team. Analyze, break-down and store reports for investigative staff to utilize.
• Support Investigative staff in collecting, collating, analyzing and interpreting data and/or documents in a timely, accurate fashion, necessary conduct an investigation and/or subpoena fulfillment.

What you bring

Education/Experience

• Bachelor’s degree or relevant experience in lieu of degree required
• Two (2) years’ experience with Nasco claim processing; and one (1) year experience with NCompass inquiry handling.

Knowledge

• Requires specific knowledge of claims processing and customer service systems (NASCO adjustment and pend processing, UPS, UCSW, Research Station, Cognos, and Image/FileNet).
• Prefer knowledge of ITS/Blue card process.
• Prefer knowledge in Microsoft products (Word, Excel, and Access).

Skills and Abilities

• Requires demonstrated ability in MS Office applications, in particular Excel and Access.
• Requires strong organizational skills.
• Requires strong interpersonal skills.
• Prefers strong analytical skills and the ability to interpret data and conduct root cause analysis.

Why Horizon?

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. If you are passionate about making an impact, we’d love to hear from you!

Salary Range

$50,100 - $67,095

​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:

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

Disclaimer

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

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.