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 This position is accountable for analytical and investigative activities (external and internal) related to claims, enrollment, accounting and other operations to detect, receive and review suspected fraud and to complete cases with all information and analysis for resolution. This is a senior level investigator expected to conduct and resolve investigations and manage their case load with limited management/supervisor oversight. What You'll Do - Detects fraudulent activities by subscribers, providers, groups, employees and other parties. - Decides the most efficient and effective method of investigation appropriate for each individual case. - Prepares and documents fraud cases, assembling evidence for potential prosecution or civil litigation. - Provides evidence and/or testifies in cases where law enforcement agencies pursue prosecution. - Personally handles field investigation work; and coordinates efforts with law enforcement state agencies and claims stakeholders. - Represents the Company in conducting complex and potentially multi-million dollar settlement negotiations with attorneys and/or other responsible parties (representing providers, enrolled groups and individual subscribers). - Serves as Company's representative in testifying in legal proceedings as required in fraud cases. - Up to date and Knowledgeable about all applicable fraud statutes; Local, state and federal to ensure duties and assignments are carried out within the requirement of applicable law and local office expectations. - Additional personal and professional attributes that are critical to successful performance: What You Bring Education/Experience: - Bachelors Degree Required - Minimum 2 yrs claims, customer service or relevant law enforcement experience required. - ITS/Blue Card knowledge preferred Additional licensing, certifications, registrations: - AHFI, CFE, or CPC certifications preferred - Prefers licensing in medical field. - Will consider advanced degree in lieu of certification. Knowledge: - Requires in depth knowledge of health insurance operations (i.e. claims, enrollment, underwriting, etc.) - Prefers working knowledge of NJ Criminal and Civil Law relative to health insurance fraud. - Prefers working knowledge of investigative process Skills and Abilities: - Requires excellent verbal and written communication skills. - Requires the ability to effectively handle and defuse confrontational situations. - Requires demonstrated ability in MS Office applications, in particular Excel and Access. - Requires strong organizational skills. - Requires demonstrated ability to conduct interviews/interrogations. - Requires the ability to create and interpret databases using multiple software applications. 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: $63,000 - $84,420 ​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.

• Align technology solutions with business strategies • Identify opportunities to apply technologies to business processes • Inform and advise customers on system functionalities • Develop and maintain effective relations with customers, IT personnel, and vendors • Recommend updates based on technology trends

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT. Work Schedule: This role primarily supports Eastern Time hours. Position Purpose: The Senior Health Care Analyst provides analytic support for financial modeling, trend analysis, therapeutic class strategy, and initiative implementation and measurement. Develops custom reports and models used in identifying issues, trends, patterns and relationships to be applied in financial and operational decisions. - Develops financial models to project cost or estimate savings for specific business decisions. - Develops and manages therapeutic class cost and utilization projection models to support budget forecasting, pricing, and strategy development. - Develops exception reporting and conducts drill down analysis to proactively identify specific opportunities and risks that warrant assessment by the Strategy Development Committee. - Monitors projection targets. Analyzes, researches, and interprets results, variances, and trends. - Prepares and maintains strategy documents for therapeutic classes. - Prepares and communicates trend analysis and recommendations verbally and in writing to committees, clinical staff, management, and clients. - Develops and manages reporting templates used to analyze and interpret data. - Designs complex ad hoc reports to support a variety of functional areas. - Advises Healthcare Analysts in producing reports and interpreting data. Education/Experience: - Bachelor’s degree in business, finance, public health, health informatics or related field required. Master's degree preferred. - Minimum five years related experience with minimum two years financial modeling experience required. - Experience in Healthcare analytics of financial/clinical data, including claims analysis, cost of care, or utilization trends, with strong knowledge of analytical techniques such as data modeling, trend analysis, and root cause analysis strongly preferred. - Experience using advanced analytical and reporting tools such as SQL, R, Python, Power BI, Tableau, or similar tools to extract, analyze, and validate data, with an emphasis on hands-on querying and data interpretation strongly preferred. - Experience identifying drivers of cost, explaining variances, and translating findings into actionable insights for business and clinical stakeholders strongly preferred. - Experience presenting analysis and recommendations to leadership audiences (Director level and above), with the ability to clearly communicate complex data in a concise and meaningful way strongly preferred. By applying to this requisition, you acknowledge and understand that you may be considered for other job opportunities for which Centene believes you may be qualified. Pay Range: $70,100.00 - $126,200.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

• Manage complex configuration changes for health plan partners • Ensure claims data flows accurately and reliably through Availity’s platform • Analyze and validate business requirements, ensuring requests are accurate and complete • Configure receiver configurations using Availity’s internal tool EPDM • Serve as a key point of contact for connectivity and data issues • Perform functional testing and support production releases • Participate in monthly and minor production releases • Work closely with internal teams such as Health Plan Analysts, Account Management, and Payment Accuracy