INVESTIGATIVE ANALYST (HYBRID)

Socket.dev; Toronto; On-site; CAD 60,000 - 91,000; Full time

Job summary

GreenShield is seeking an experienced investigator to support the Claim Watch program, identifying complex fraud patterns and leading investigations across health care claims.

You will analyze data, conduct interviews, and collaborate with providers and regulators to improve controls. Strong knowledge of AI tools and a background in health care benefits are essential, with a commitment to continuous learning and integrity.

Qualifications

• Minimum 5 years’ experience in audit and fraud detection, health care benefit administration and/or investigations.
• Ability to exercise independent judgment in complex investigative scenarios.
• Working knowledge with AI technology.
• Strong analytical and critical-thinking skills; translate findings into recommendations.

Responsibilities

• Support the delivery and evolution of the Claim Watch program, including identification and leading of complex investigations.
• Leverage reporting and AI to identify abuse, misuse, and fraudulent claims activity.
• Conduct complex interviews with providers and plan members; exercise independent judgment in ambiguous situations.
• Analyze utilization trends and develop profiling criteria to support fraud controls.
• Identify cost-containment and risk-mitigation opportunities; include automation enhancements.
• Develop and implement preventative fraud measures and support audits, compliance, and risk activities.
• Collaborate with internal teams and external stakeholders including providers and law enforcement.
• Produce executive-level reporting translating findings into actionable insights for leadership.

Skills

Fraud detection

Audit

Healthcare benefits

Investigations

AI technology

Data analysis

Leadership

Regulatory knowledge

Education

University degree or college diploma in business or related discipline

Tools

Microsoft Office (Access, Excel, Word)

BI/Data Visualization tools

Job description

WHO WE ARE

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.

THE ROLE IN A NUTSHELL

Base Salary: CAD $59,688.00 - 91,109.00

Investigation and Analysis

• Support the delivery and evolution of the Claim Watch program, including identification and leading of complex and high‑risk investigations.
• Leverage reporting and AI technology to identify, research, and analyze abuse, misuse, and fraudulent claims activity with a focus on emerging patterns and systemic risk.
• Conduct complex interviews with providers and plan members and exercise independent judgment in ambiguous or precedent‑setting situations.
• Analyze utilization trends and develop provider and plan member profiling criteria to support preventative and detective fraud controls, using reporting and AI tooling.
• Identify and recommend cost‑containment and risk‑mitigation opportunities, including automation and control enhancements.
• Develop and implement preventative fraud measures and support audit, compliance, and enterprise risk activities.
• Collaborate across departments and with external stakeholders, including providers, associations, and law enforcement.
• Produce executive-level reporting and analytics that translate complex investigative findings, emerging risks, and fraud trends into actionable business insights and strategic recommendations for leadership and clients.
• Provide mentorship and guidance to investigative staff and contribute to continuous improvement of investigative practices.
• Contribute to and analyze the development of investigative reporting requirements, dashboards, and performance metrics, identifying opportunities to improve visibility into fraud, abuse, misuse, operational effectiveness, and emerging risks.
• Provide trainingand mentoringto peers and team members.
• Support the client/partner specific ClaimWatch governance framework.

WHO WE’RE LOOKING FOR

• Minimum of5years’ experience in audit and fraud detection, health care benefit administration and/or in conducting investigations.
• Demonstrated ability to exercise independent judgment and make defensible decisions in complex investigative scenarios.
• Working knowledge with AI technology.
• Exceptional analytical and critical-thinking skills with demonstrated ability to synthesize large and complex data sets, identify emerging patterns, assess risk, and translate findings into strategic recommendations.
• Experience contributing to preventative fraud strategies, automation, or intelligent audit approaches (asset).
• Demonstrated leadership, mentorship, and ability to influence outcomes across teams without direct authority.
• Demonstrated commitment to continuous learning and professional development, with a strong curiosity for emerging technologies, fraud schemes, industry trends, data analytics, and investigative methodologies.
• University degree or college diploma in business or related discipline required.
• Strong interpersonal skills and the ability to communicate to all levels of internal and external customers both orally and written.
• Understanding of group Health & Dental administration.
• Excellent customer service with a drive todeliver exceptional service.
• Demonstrated capability to meet objectives and milestones when working independently and on project teams.
• Highly organized and able to balance multiple tasks in a fast-paced environment.
• Working knowledge of relevant federal and provincial legislation, regulations and the judiciary system (Including but not limited to: PIPEDA, Regulated Health Professions Act, Privacy Act) would be an asset.
• Proficiency with Microsoft Office tools, including Access, Excel, Word, and other business applications and reporting tools.
• Experience using Business Intelligence (BI) and Data Visualization platforms.
• Ability to travelwithin Canada.

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 adifference together.

Here’s to Better Health for All!

A FEW MORE DETAILS

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.

Providing this information gives GS consent to use your personal information to assess your suitability for specific positions, future opportunities or for your personnel file. Your résumé will be held in strict confidence and will be viewed only by the Organization. Information may be stored outside of Canada and could be used for aggregate 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.