Investigation Analyst – Provider Risk

Manulife • Waterloo, ON

2d • CA$43,875 - CA$73,125 • Hybrid

About The Position

Manulife’s Group Benefits Health and Dental Claims Risk Management department is a diverse and dynamic team delivering a broad range of services in support of key operational objectives. Our responsibilities include digital claims risk management, claims abuse management and monitoring programs, fraud investigations, data analytics, and claims experience management. The effective management of health and dental claims experience is imperative to the success of the group benefits operations.

The Investigation Analyst will draw on their in-depth analytical skills, investigative mindset, customer focus, group benefits background and understanding of the Canadian Healthcare environment/regulation to help manage ongoing priorities in the delivery of risk management.

A key focus of the Investigation Analyst is the prevention, detection, and investigation of fraud and abuse specific to health care providers. This role will proactively identify risk, champion mitigation strategies, conduct provider investigations and take actions to protect Manulife benefit plans from fraud. The role may liaise externally with industry contacts and vendors, and internally with Legal, Compliance, Advanced Analytics, Marketing, Customer Service, Client Relations, Ombudsman and the Field as needed.

This role reports to the Senior Manager, Fraud Risk Management, and helps to protect plan sponsors and members from the negative impacts of claims fraud. This role is focused on provider risk mitigation, which is a key part of the foundation for our investigation programs and a vital part of claims risk management.

Requirements

• Knowledge of Group Benefits
• Knowledge of the Canadian healthcare environment, service delivery model and regulation
• University degree or equivalent work experience

Nice To Haves

• Bilingualism (English and French) is an asset. If the successful candidate is in Québec, proficiency in both languages will be required to support clients from various provinces outside of Quebec.
• CFE designation is an asset
• Knowledge of fraud and abuse risk, and techniques to manage risk
• Strong research, problem solving and decision-making skills
• Ability to manage contentious interactions with various stakeholders
• Excellent oral communication (both phone and face to face) and written communication skills
• Intermediate or higher data analysis skills with expertise using Excel and other data mining software
• Demonstrated investigation skills with attention to detail
• Ability to be creative, critical and aggressive in managing audit and investigative activities
• Organizational skills and the ability to manage multiple conflicting priorities

Responsibilities

• Perform risk-based data profiling and analysis to identify trends and outliers in various categories for further review and investigation
• Lead and support audit programs; coordinating, assessing, and making decisions on investigations
• Take initiative and lead investigations to successful conclusion including the preparation of criminal and regulatory complaints
• Conduct interviews of plan members, providers of service and others
• Create written audits and other correspondence to plan members, providers of service and others
• Engages, interacts and consults with various internal contacts such as Customer Service, Legal, Client Relations, Medical Consultants, Regional Group Office and external stakeholders such as Health Practitioner Regulatory Bodies, Colleges and Associations, and Plan Sponsors
• Lead, support and implement key investigative projects
• Comfortable delivering effective presentations to new and existing clients

Benefits

• health, dental, mental health, vision, short- and long-term disability, life and AD&D insurance coverage, adoption/surrogacy and wellness benefits, and employee/family assistance plans.
• various retirement savings plans (including pension and a global share ownership plan with employer matching contributions)
• financial education and counseling resources.
• generous paid time off program in Canada includes holidays, vacation, personal, and sick days
• full range of statutory leaves of absence.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree