Claims Management Manager (Hybrid)
About The Position
GreenShield is seeking a strategic and analytical Claims Management Manager responsible for building and executing a comprehensive claims oversight framework that enhances financial integrity, operational efficiency, and member experience. This individual contributor role will serve as a key enterprise resource, driving initiatives across auditing, anomaly detection, and adjudication optimization. The Manager will collaborate with finance, pricing, fraud, automation, and product teams to identify cost drivers, mitigate risks, and ensure claims processes align with organizational objectives and industry benchmarks.
Requirements
- Bachelor’s degree in Finance, Mathematics, Data Analytics, or a related field.
- ASA Required.
- 5+ years of experience in claims management, health benefits, or insurance operations.
- Strong analytical and investigative skills with the ability to interpret complex data and identify actionable insights.
- Proficiency in data analysis tools and platforms (SQL, R, Tableau, Power BI).
- Experience with auditing, anomaly detection, and process optimization.
- Ability to collaborate across multiple teams and influence enterprise-level decisions.
- Excellent attention to detail and accuracy, with a focus on meeting deadlines.
- Proficiency in English is required for this position.
Nice To Haves
- Master’s degree would be an asset.
- FSA Preferred.
Responsibilities
- Evaluate existing plan designs for gaps or inefficiencies and recommend enhancements such as Health Spending Accounts (HSAs), maximums, and prior authorization criteria.
- Conduct regular audits of plan setup in administrative systems to ensure accurate adjudication logic.
- Partner with internal stakeholders to validate plan configurations and prevent operational errors.
- Collaborate with Financial Planning & Analytics and pricing teams to develop dashboards and predictive models for identifying emerging cost drivers and utilization patterns.
- Build predictive models for high-cost claims, chronic disease prevalence, and utilization patterns.
- Develop scenario analysis for catastrophic claims and emerging health risks.
- Analyze Customer Relationship Management and Claims Data Management data to detect unusual claims activity and feed insights into fraud detection and plan design workflows.
- Assess provider-level analytics to uncover patterns contributing to overbilling or inflated costs.
- Develop dashboards for claims trend by claim type and provide actionable intelligence to leadership.
- Deliver quality insights on cost drivers and emerging risks.
- Support executive decision-making with scenario modeling.
- Perform deep-dive investigations into transactional data to identify adjudication rule gaps.
- Work with automation and plan build teams to refine rules and improve processing accuracy.
- Recommend system enhancements to reduce manual interventions and improve adjudication speed.
- Partner with AR/Billing teams to reconcile member counts, commission structures, and recoveries.
- Validate that billing accurately reflects plan utilization and enrollment setup.
- Ensure commission recovery processes align with claims adjustments.
- Work closely with fraud teams to analyze recovered cases and integrate insights into claims workflows.
- Explore partnerships with external fraud analytics vendors to strengthen detection capabilities.
Benefits
- Base Salary: CAD $94,406.00 - 142,069.00
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What This Job Offers
Job Type
Full-time
Career Level
Manager
