Investigation Analyst, Drug

OverviewJoin a dynamic team within the Group Benefits Health and Dental Claims Risk Management department, delivering digital claims risk management, fraud investigations, data analytics, and claims experience oversight. This role identifies and mitigates fraud and abuse in drug claims, contributing to the integrity and sustainability of our benefits programs.The Drug Investigation Analyst, Investigation Services applies Group Benefits knowledge, attention to detail, problem solving, customer service, investigation, and data analysis to identify, investigate and prevent fraud and abuse of drug claims. The role may work with the Sr. Investigation Analyst and/or a consulting Pharmacist on projects and initiatives.Position ResponsibilitiesPerform risk-based data profiling and analysis to identify trends and outliers in various categories for review and investigationLead and support audit programs; coordinate, assess, and make decisions on investigationsTake initiative and independently lead investigations to a successful conclusionConduct interviews of plan members, providers of service, and others as requiredCreate written audits and other correspondence to plan members, providers of service, and othersEngage/interact/consult with internal contacts (Customer Service, Legal, Client Relations, Medical Consultants, Regional Group Office) and external stakeholders (Health Practitioner Regulatory Bodies, Colleges and Associations, Plan Sponsors)Lead, support and implement key investigative projectsProvide technical expertise to internal customers to troubleshoot claims payments, resolve escalated complaints, and support issue trendsProvide oversight of the drug audit program and risk assessment of claim initiatives and client customizations related to the drug benefitReview and analyze high-dollar drug claims and narcotics usageAttend client meetings as requiredAttend litigation/arbitration sessions in court if requiredRequired QualificationsPost-secondary education or equivalent experience – pharmacy technician or pharmacy assistant background would be an assetGeneral understanding of medical terminology, diseases, and drug formulariesPreferred QualificationsGood presentation and negotiation skillsStrong analytical, research, problem-solving and decision-making skillsEffective project management capabilitiesAbility to review and analyze critical data to make formal recommendations for process improvementsComfortable speaking with external parties such as pharmacists, health care providers, drug manufacturers, government agencies, plan members and plan sponsorsAbility to decipher health industry information and relate it to Group Benefits’ plansProven ability to manage/schedule a fluctuating, unpredictable and stressful workloadKnowledge of Group BenefitsKnowledge of the Canadian healthcare environment, service delivery model and regulationExcellent understanding of third-party claims adjudication as it relates to Pharmacy benefitsKnowledge of fraud and abuse risk, and techniques to manage riskStrong research, problem solving and decision-making skillsAbility to manage contentious interactions with various stakeholdersExcellent oral and written communicationIntermediate data analysis skills with expertise using Excel and other data mining softwareDemonstrate investigation skills with attention to detailKnowledge of privacy, civil and criminal legal risks and processesWhen you join our teamWe’ll empower you to learn and grow the career you want.We’ll recognize and support you in a flexible environment where well-being and inclusion are valued.As part of our global team, we’ll support you in shaping the future you want to see.#LI-HYBRIDAbout Manulife and John HancockManulife Financial Corporation is a leading international financial services provider. To learn more about us, visit our story page—note: no external link included in this refined version.Manulife is an Equal Opportunity EmployerAt Manulife/John Hancock, we embrace diversity and foster an inclusive work environment. We are committed to fair recruitment, retention, advancement and compensation, and we administer all practices without discrimination on the basis of race, ancestry, place of origin, colour, ethnic origin, citizenship, religion or religious beliefs, creed, sex (including pregnancy and pregnancy-related conditions), sexual orientation, genetic characteristics, veteran status, gender identity, gender expression, age, marital status, family status, disability, or any other protected ground by law.It is our priority to remove barriers to provide equal access to employment. A Human Resources representative will assist applicants who request a reasonable accommodation during the application process. To request an accommodation, contact recruitment@manulife.com.Salary and LocationMontreal, Quebec • HybridSalary range is expected to be between CAD 51,375.00 and CAD 85,625.00. The actual salary will vary based on location and experience. Eligible employees may participate in incentive programs. #J-18808-Ljbffr