Investigation Analyst – Member Risk

Manulife; Southwestern Ontario; On-site; CAD 60,000 - 80,000; Full time

Job summary

A major insurance firm in Ontario seeks an Investigation Analyst to prevent and investigate fraud related to plan members. This role demands strong analytical capabilities, a thorough understanding of the Canadian healthcare system, and the ability to engage various stakeholders effectively. The ideal candidate should possess a university degree and have experience in group benefits, alongside strong data analysis and communication skills.

Qualifications

• Knowledge of the Canadian healthcare environment and regulations.
• CFE designation is an asset.
• Demonstrated investigation skills.

Responsibilities

• Perform risk-based data profiling and analysis.
• Lead and support audit programs.
• Conduct investigations and interviews.

Skills

Knowledge of Group Benefits

Excellent oral communication skills

Intermediate data analysis skills

Strong research and problem-solving skills

Attention to detail

Education

University degree or equivalent work experience

Tools

Excel

Data mining software

Job description

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 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 related to plan members. This role will proactively identify risk, champion mitigation strategies, conduct plan member and provider investigations and take actions to protect Manulife benefit plans from fraud.

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 plan member risk mitigation, which is a key part of the foundation for our investigation programs and a vital part of claims risk management.

Position 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
• Engage, interact and consult 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
• Deliver effective presentations to new and existing clients
• Travel may be required for this role, including the ability to work outside of core working hours

Required Qualifications:

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

Preferred Qualifications:

• 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 and written communication skills
• Intermediate or higher data analysis skills with expertise using Excel and other data mining software
• Demonstrate 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

Manulife is an Equal Opportunity Employer. At Manulife/John Hancock, we embrace our diversity. We strive to attract, develop and retain a workforce that is as diverse as the customers we serve and to foster an inclusive work environment that embraces the strength of cultures and individuals.