Claims Management Manager

GreenShield; Toronto; On-site; CAD 90,000 - 130,000; Full time

Job summary

GreenShield, a proudly Canadian non‑profit health care and insurance organization, seeks a strategic Claims Management Manager to build and oversee a comprehensive claims oversight framework. You will drive auditing, anomaly detection, and adjudication optimization while collaborating with finance, pricing, fraud, automation, and product teams to identify cost drivers and mitigate risks.

You will develop dashboards, predictive models, and scenario analyses to inform leadership and improve member

Qualifications

• Bachelor’s degree in Finance, Mathematics, Data Analytics, or related field.
• 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.

Responsibilities

• Evaluate claims oversight and auditing: assess design gaps and optimize with HSAs, max limits, and prior authorization criteria.
• Audit plan setups to ensure accurate adjudication logic.
• Partner with stakeholders to validate plan configurations and prevent errors.
• Develop dashboards and predictive models for cost drivers and utilization.
• Build models for high-cost claims, chronic disease prevalence, and utilization trends.
• Create scenario analyses for catastrophic claims and emerging health risks.
• Analyze CRM and claims data to detect unusual activity and feed insights into fraud detection.
• Assess provider analytics to uncover patterns contributing to overbilling or inflated costs.
• Develop dashboards for claims trends and provide leadership with actionable insights.
• Support executive decisions with scenario modeling.
• Perform deep-dive investigations 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 to reconcile member counts, commissions, and recoveries.
• Validate billing reflects plan utilization and enrollment; align with adjustments.
• Collaborate with fraud teams to analyze recovered cases and strengthen detection.

Skills

Analytical thinking

Investigative skills

Cross-functional collaboration

Data interpretation

Problem solving

Education

Bachelor’s degree in Finance, Mathematics, Data Analytics, or related field

Master’s degree would be an asset

Tools

SQL

R

Tableau

Power BI

Job description

GreenShield is a proudly Canadian, national non-profit health care and insurance organization, driven by our mission of Better Health for All. We believe health care is a right, not a privilege, and we are committed to improving health outcomes, advancing health equity, and building a future where every Canadian can reach their full health and well-being potential.

Through our unique integrated payer-provider ("payvider") model, we offer insurance, administer benefits, and pay claims as a ‘payer’ while offering health care services such as mental health, pharmacy, telemedicine, and chronic disease management as a ‘provider’. As a non-profit social enterprise without shareholders, we reinvest our excess earnings to directly support underserved communities. Through GreenShield Cares, we positively impacted the health and well-being of over one million Canadians between 2020 and 2025. What’s driving us now is the commitment to measurably impact an additional three million Canadians by 2030 – across mental health, essential medicines, and chronic disease management – through scalable initiatives that deliver meaningful change in pursuit of our mission of Better Health for All.

At GreenShield, our culture is where purpose meets passion and performance. Our teams work as one to deliver meaningful, measurable impact for the people and communities we serve.

WHO WE ARE

When it comes to health, we’re always looking for ways to push for better. It’s why we were founded in the first place. In 1957, our founder, pharmacist William Wilkinson, witnessed a mother sacrifice her health by foregoing her own medicine to pay for her sick daughter’s prescription. He knew there had to be a better way. So, he introduced North America’s first prepaid drug plan, and GreenShield was born as a not-for-profit with a mission to support better health for all Canadians.

We aren’t just a health and benefits company. We’re the only not-for-profit social enterprise that brings worlds of coverage and care together, all in one place.

We’re noble challengers, purposefully building a better way and we need the best people to help us create a more holistic approach that takes care of the mind and body.

Our mission is to create better health for all Canadians, and we know that starts with our employees.

THE ROLE IN A NUTSHELL

We are 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.

Roles and Responsibilities

1. Claims Oversight and Auditing

• 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.

2. Anomaly Detection and Trend Analysis

• 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.

3. Strategic Reporting & Insights

• 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.

4. Root Cause Analysis and Rule Optimization

• Perform deep‑drive 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.

5. Billing and Financial Alignment

• 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.

6. Fraud, Waste, and Abuse Collaboration

• 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.

WHO WE'RE LOOKING FOR

We’re not looking for just anyone. We’re looking for a unique individual with a big brain and a big heart who wants to help us create better health for all Canadians.

• Bachelor’s degree in Finance, Mathematics, Data Analytics, or a related field. Master’s degree would be an asset.
• 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.

THE CULTURE

We believe a career should be meaningful. Not just a means to earn a living. Our culture is one where everyone's voice is heard and valued. Because that’s what it takes to create better health for all. We dare to challenge the status quo. And we’re driven by people who have challenged theirs. We believe that your workplace should empower you to be the best version of yourself. That’s why we provide a place where you can be inspired, challenged, and rewarded.

Where your growth means our growth.

Where your voice is heard and valued.

Where your work has purpose. And purpose matters.

We believe our people are critical to our overall success. Inclusivity makes us a stronger, smarter and more informed organization. Being intentionally inclusive of diverse backgrounds, perspectives and experiences will enhance our company culture to positively impact how we support our communities. A career at GreenShield isn’t just about personal achievements, it's about making a difference together.

Here’s to Better Health for All!

Proficiency in English is required for this position. As part of this role, you will be required to communicate with colleagues or customers who use English as their primary language. By requiring English proficiency for this position, we aim to ensure that our employees can excel in their roles, collaborate, and communicate effectively, and contribute to the success of our organization.

GS supports diversity, equity and inclusion in our teams and communities, and we value the unique contributions made by all. Even if your experience doesn’t align perfectly to every requirement, we invite you to apply. We encourage applications from all candidates and will accommodate needs under human rights legislation throughout all stages of the recruitment and selection process. Please let us know of any accommodation through [e-mail]. Information received relating to accommodation will be addressed confidentially.

AI Usage - GreenShield leverages AI to help produce Job Descriptions, and ideate on interview questions. We also leverage AI for interview transcription support.