[Remote] Special Investigations FEP Program Lead

Note: The job is a remote job and is open to candidates in USA. Horizon Blue Cross Blue Shield of New Jersey is a health solutions leader dedicated to improving healthcare quality and affordability. The Special Investigations Federal Employee Program Lead oversees all FEP-related activities to ensure compliance with federal health benefits requirements and leads healthcare fraud investigations impacting the FEP. Responsibilities • Provides reports and status updates to Horizon-BCBSNJ Blue Plan Executives as well as upper level management within Horizon-BCBSNJ’s FEP program, BCBSA FEP Directors Office and OPM-OIG Section Chiefs • Responsible for creating and presenting quarterly reports to Special Investigations Senior Management (VP & Director) regarding the SIU FEP operations • Responsible for monitoring and providing oversight while updating FSTS consistent with requirements outlined in the FEP Carrier Letter and BCBSA policies & procedures • Manages and facilitates SIU program audits and yearly certifications of the FEP program by the Blue Cross Blue Shield Association and the Office of Personnel Management, Office of Inspector General • Liaise with the Blue Cross Blue Shield Association SIU Executives, and OPM-OIG’s Section Chief and Criminal investigators on Horizon Blue Cross Blue Shield of New Jersey’s SIU current cases. Prepares documents, conducts presentations and provides ongoing updates through resolution • Leads internal and external investigations (approximately 375 to 400 cases) which consists of collecting, collating, analyzing and interpreting data in a timely, accurate fashion, securing necessary documentation to resolve open cases; following compliance measurements for established procedures and guidelines outlined in the latest Federal Employee Health Benefits (FEHB) Carrier Letter for conducting and leading audits/investigations • Manages and maintains records on all claim savings from the Pre-Payment Review team and any recoveries that impact the FEP. When Providers are placed on a Pre-Payment Review the Program Lead would review the medical records to determine whether to pay or deny claims. If we deny claims, we need to report that amount saved to the FEP program on a monthly basis • Provides oversight and direction to our Investigators conducting healthcare fraud investigations, which impact the FEP. Currently, there are 391 cases that impact the FEP program • Actively participates in any and all litigation involving the FEP Program; prepares files for court, provides testimony and records all settlement outcomes • Completes initial intake and follow up on all calls from the Fraud hotline that impact the FEP program Skills • BA/BS Required • Certification (Certified Fraud Examiner (ACFE), Certified Professional Coder (CPC), or Accredited HealthCare Fraud Investigator (AHFI). However, if they don't already have this certification, the expectation is for the candidate to acquire one of these certifications within the first 6 months of the hire • 5+ years' experience in conducting fraud investigations • Prior supervisory experience a plus • Excellent verbal and written communication skills • The ability to effectively handle confrontational situations • Demonstrated ability in MS Office applications, in particular Excel and Access • Strong organizational skills • Strong interpersonal skills • Knowledge of the FEP Program with regards to Special Investigations • Knowledge of the FEP SIU Tracking System (FSTS) • Knowledge of health insurance operations (i.e. claims, compliance, enrollment, underwriting, etc.) • General knowledge of FEP claims processing and customer service systems (NASCO adjustment and pend processing, UPS, UCSW, Research Station, Cognos, and Image) • Knowledge in Microsoft products (Word, Excel, and Access) • Knowledge of medical coding • Strong analytical skills and the ability to interpret data and conduct root cause analysis Benefits • Comprehensive health benefits (Medical/Dental/Vision) • Retirement Plans • Generous PTO • Incentive Plans • Wellness Programs • Paid Volunteer Time Off • Tuition Reimbursement Company Overview • Horizon Blue Cross Blue Shield of New Jersey is a company that provides health insurance products. It was founded in 1932, and is headquartered in Newark, New Jersey, USA, with a workforce of 5001-10000 employees. Its website is http://www.horizonblue.com. Apply Now Apply Now