Special Investigations FEP Program Lead

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 Special Investigations Federal Employee Program (FEP) Lead is responsible for oversight of all FEP related activities of Special Investigations to insure the Horizon BCBSNJ Special Investigations program is operating consistent with the requirements of the Federal Employee Health Benefits (FEHB) Carrier Letter as well as the Blue Cross Blue Shield Associations (BCBSA) FEP Anti-Fraud policies and procedures. The program lead will be the primary contact and responsible for overall oversight of program integrity audits conducted by the BCBSA as well as audits conducted by the Office of Personnel Management, Office of Inspector General (OPM-OIG) as well as the Horizon BCBSNJ Internal Audit Department. The program lead will face off to senior and executive level management of the BCBSA FEP program, Section Chiefs within OPM-OIG, senior management within Horizon BCBSNJ’s FEP Operations, and the Horizon BCBSNJ Compliance Department. The program lead will lead, manage and take accountability for the annual BCBSA FEP Certification which includes the review and reporting of approximately Special Investigation cases (approximately 400 cases) as well as provide financial information for all cases ranging from $2 to $2.5 Million in FEP fraud identified. The program lead will also lead healthcare fraud investigations that impact the FEP.

What You'll Do

• 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.

What You Bring

Education/Experience:

• 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.

• Prefers knowledge of the FEP Program with regards to Special Investigations.

• Prefers knowledge of the FEP SIU Tracking System (FSTS).

• Prefers knowledge of health insurance operations (i.e. claims, compliance, enrollment, underwriting, etc.).

• Prefers general knowledge of FEP claims processing and customer service systems (NASCO adjustment and pend processing, UPS, UCSW, Research Station, Cognos, and Image).

• Prefers knowledge in Microsoft products (Word, Excel, and Access).

• Prefers knowledge of medical coding.

Skills and Abilities:

• Requires excellent verbal and written communication skills.

• Requires the ability to effectively handle confrontational situations.

• 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.

Travel % (If Applicable):

• Travel as needed to support investigative activity within Company's service area.

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:

$79,100 - $105,945

​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.