Claims Management Manager (Hybrid)

Green Shield Canada (GSC); Toronto; On-site; CAD 94,000 - 142,000; Full time

Job summary

Green Shield Canada (GSC) is seeking a strategic and analytical Claims Management Manager to build and execute a comprehensive claims oversight framework. You will drive auditing, anomaly detection, and adjudication optimization across cross-functional teams to improve financial integrity and member experience.

In this role, you will collaborate with finance, pricing, fraud, automation, and product teams to identify cost drivers, mitigate risks, and ensure claims processes align with

Qualifications

• Bachelor’s degree in Finance, Mathematics, Data Analytics, or a related field; Master’s degree would be an asset.
• ASA required; FSA preferred.
• 5+ years of experience in claims management, health benefits, or insurance operations.

Responsibilities

• Evaluate existing plan designs for gaps or inefficiencies and suggest enhancements (HSAs, maximums, prior authorization).
• Audit plan setups in systems to ensure accurate adjudication logic.
• Collaborate with finance, pricing, fraud, automation and product teams to identify cost drivers and risks.
• Develop dashboards and predictive models for cost drivers, utilization, and high-cost claims.
• Perform root-cause analysis to refine adjudication rules and improve processing accuracy.
• Partner with AR/Billing to reconcile counts, commissions, and recoveries.

Skills

SQL

R

Tableau

Power BI

Auditing

Data analysis

Education

Bachelor's degree in Finance/Math/Data Analytics

ASA Certification

FSA Preferred

Tools

SQL

R

Tableau

Power BI

Job description

WHO WE ARE

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

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

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

THEROLE IN A NUTSHELL

Base Salary: CAD $94,406.00 - 142,069.00

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-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.

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.
• ASA Required.FSA Preferred.
• 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 ameans to earn a living. Our culture is one where everyone's voice is heard andvalued. Because that’s what it takesto create better health for all. We dare to challenge the status quo. And we’redriven by people who have challenged theirs. We believe that yourworkplace should empower you to be the best version of yourself. That’s why we provide aplace 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 arecritical to our overall success. Inclusivity makes us a stronger, smarter andmore informed organization. Being intentionally inclusive of diversebackgrounds, perspectives and experiences will enhance our company culture topositively impact how we support our communities. A career at GreenShield isn’t just about personalachievements, it's about making adifference together.

Here’s to Better Health for All!

A Few MORE DETAILS

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

GS supports diversity, equity andinclusion in our teams and communities, and we value the unique contributionsmade by all. Even if your experience doesn’t align perfectly to everyrequirement, we invite you to apply. We encourage applications fromall candidates and will accommodate needs under human rights legislationthroughout all stages of the recruitment and selection process. Please let usknow of any accommodation through [e-mail]. Information received relating toaccommodation will be addressed confidentially.

Providing this information givesGS consent to use your personal information to assess your suitability forspecific positions, future opportunities or for your personnel file. Yourrésumé will be held in strict confidence and will be viewed only by theOrganization. Information may be stored outsideof Canada and could be used foraggregate statistical purposes (which uses no personal identification).

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