Claims Verification Analyst

The Claims Verification Analyst is responsible for supporting health and dental claims fraud risk controls by authenticating claim submissions, identifying, and investigating issues for action and resolution, and escalating key control issues to the claims risk management team. The Claims Verification Analyst will conduct health and dental claims audits through reviewing receipt evidence and supporting documentation, contacting providers and/or plan members to validate submissions, verify provider licensing through internet searches and contact with professional associations and colleges, and follow through on actions from these reviews for successful outcomes. The auditor will work with our various internal departments, including Technical Services, Customer Service, Investigation Services and H&D Operations for resolution on claims submission issues. The Claims Verification Analyst reports to the Program Manager, Investigation Services, and helps to protect plan sponsors and members from the negative impacts of claims fraud. This role is focused on risk detection, which is the foundation for our investigation programs and a vital part of claims risk management. Position Responsibilities: Reviews audit evidence submissions by plan members to authenticate information, identifies areas of concern, actions issues for resolution, and obtains/requests additional evidence required on suspect claim submissions. Validates irregular Internet transaction activity through phone call interviews with providers and/or plan members and secures evidence on discrepancies as part of information gathering on suspect claim submission activity. Requests supporting documentation from plan members and authenticating information, identifying issues and gaps for further review and resolution. Identifies fraudulent claims, documents and gathers evidence, and supports ongoing management of investigation activity Confirms provider’s licensing credentials and legitimate business establishments through Internet searches and by contact with professional associations and colleges. Actions and resolves issues for successful audit outcomes and escalates key provider control issues to the e-commerce control management team Analyzes data to identify anomalies, trends and patterns; and supports testing, and documentation of new risk controls for continuous review of all Internet submission activity Supports awareness on e-commerce control and operational workflow issues by providing direction and information to internal Group Benefit departments such as Call Center and various Health and Dental Operation departments Required Qualifications: Knowledge of privacy, civil and criminal legal risks, and processes Preferred Qualifications: Ability to manage contentious interactions with various stakeholders and take control of stressful situations with tact and diplomacy Excellent oral communication skills and ability to interview service providers, plan members and others for successful audit outcomes Excellent written communication skills Resourceful with a proven analytical, problem solving, and troubleshooting background Proficient in research and quick decision making Strong organizational skills and the ability to manage multiple conflicting priorities in a fast-paced changing environment adapting to changes are essential Ability to take-action on ideas, situations, or opportunities before being asked Ability to be skeptical, probing, creative and aggressive in conducting authentication and investigation activity When you join our team: We’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 more than just words. As part of our global team, we’ll support you in shaping the future you want to see. #LI-HYBRID Working Arrangement ハイブリッド勤務 Referenced Salary Location Waterloo, Ontario Salary range is expected to be between $39,225.00 CAD - $65,375.00 CAD If you are applying for this role outside of the primary location, please contact recruitment@manulife.com for the salary range for your location. The actual salary will vary depending on local market conditions, geography and relevant job-related factors such as knowledge, skills, qualifications, experience, and education/training. Employees also have the opportunity to participate in incentive programs and earn incentive compensation tied to business and individual performance. Manulife offers eligible employees a wide array of customizable benefits, including health, dental, mental health, vision, short- and long-term disability, life and AD&D insurance coverage, adoption/surrogacy and wellness benefits, and employee/family assistance plans. We also offer eligible employees various retirement savings plans (including pension and a global share ownership plan with employer matching contributions) and financial education and counseling resources. Our generous paid time off program in Canada includes holidays, vacation, personal, and sick days, and we offer the full range of statutory leaves of absence. If you are applying for this role in the U.S., please contact recruitment@manulife.com for more information about U.S.-specific paid time off provisions. Japanese EEO Statement マニュライフ・ファイナンシャル・コーポレーションは、「あなたの未来に、わかりやすさを」を提供する、国際的な大手金融サービスプロバイダーです。当社について詳しくは、 https://www.manulife.co.jp/ をご覧ください。 マニュライフは機会均等を是とする雇用主です。マニュライフ/ジョン・ハンコックでは、多様性を受け入れます。私たちは、サービス提供先であるお客さまと同様に、多様な人材を引きつけ、育成し、定着させ、文化や個人の力を受け入れる包括的な職場環境を促進するよう努めています。当社は公正な採用、定着、昇進、報酬に努めています。当社のすべての慣行およびプログラムは、人種、祖先、出身地、肌の色、民族的出自、市民権、宗教または宗教的信念、信条、性別（妊娠および妊娠関連の状態を含む）、性的指向、遺伝的特徴、退役軍人としての地位、性自認、性に関する表明、年齢、婚姻状況、家族状況、障害、または適用法で保護されるその他の要因に対する一切の差別を行うことなく管理されます。 雇用への平等なアクセスを提供するために、障壁を取り除くことが当社の優先事項です。人事担当者は、応募者が応募プロセス中に合理的配慮を要求する場合に協力します。配慮要求のプロセス中に共有されるすべての情報は、適用される法律およびマニュライフ/ジョン・ハンコックのポリシーに準拠した方法で保存および使用されます。申請プロセスにおいて合理的配慮を要求するには、 recruitment@manulife.com までご連絡をお願いします。 #J-18808-Ljbffr