Investigator II

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Perform analytical and investigative tasks related to claims, enrollment, accounting, and other operations to identify, receive, and assess suspected fraud.

• Prepare and document fraud cases, gathering evidence for potential prosecution or civil litigation.

• Provide evidence and/or testify in cases pursued by law enforcement agencies for prosecution.

• Conduct field investigations and collaborate with law enforcement state agencies and claims stakeholders.

• Represent the Company in intricate settlement negotiations with attorneys and other responsible parties.

• Testify in legal proceedings as necessary in fraud-related cases.

• Adhere to the procedures and guidelines specified in the latest Federal Employee Health Benefits (FEHB) Carrier Letter.

• Investigate cases affecting the FEP line of business, including investigations into FEP eligibility.

• Update and monitor the FEP SIU Tracking System with case activities, subpoenas, financial data, audits, referrals, settlements, and convictions.

• Collaborate with the BCBSA FEP SIU Consultant.

• Manage fraud hotline calls related to the FEP program.

⛳️ Requirements

• High School Diploma/GED is required.

• A minimum of 2 years of experience in claims, customer service, or relevant law enforcement is required.

• ITS/Blue Card knowledge is preferred.

• Basic understanding of health insurance operations (e.g., claims, enrollment, underwriting, etc.) is necessary.

• Basic familiarity with SIU health insurance operations.

• Excellent verbal and written communication abilities.

• Capability to effectively manage confrontational situations.

• Proven proficiency in MS Office applications, particularly Excel and Access.

• Strong organizational skills are essential.

• Willingness to travel as needed to support investigative activities within the Company's service area.

• Employees must reside in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision).

• Retirement Plans.

• Generous Paid Time Off (PTO).

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.