Manager, Special Investigations Unit

5 months ago

Mississauga, Canada ClaimSecure Full time

Reporting to the VP, Corporate Services, the manager is responsible to define and implement anti-fraud, waste and abuse (FWA) strategy for the health & dental business. Ideate, develop, implement, and monitor ClaimSecure’s FWA program to achieve program goals and milestones. Manage and train a FWA team with proficiency in all benefits lines. The role is responsible for effective communication of ClaimSecure’s FWA program, its methodologies and investigation results with the internal and external stakeholders including groups, plan members, healthcare providers, clients, and law enforcement personnel.

**What will you do?**

Primary Responsibilities:
Lead an experienced team to:

- Develop & implement anti-fraud, waste and abuse (FWA) programs for all benefit lines across Canada.
- Plan & lead investigations, audit campaigns to meet FWA program goals.
- Investigate cases of potential FWA, including data analysis and document review. Interview suspects, witnesses and analyze their testimony to determine allegations and prepare clear concise investigatory memorandum to support findings regarding potential FWA.
- Follow-up with agents and customers as needed to identify additional information in support of the case.
- Identify opportunities to improve existing investigations processes for all lines of benefits and other lines of business as ClaimSecure sees fit.
- Spearhead the implementation of automated and manual process changes to improve anti-fraud, waste, and management procedures.
- Research new technology to further automate existing processes.
- Establish and adapt rules for online anti-fraud, waste, and abuse controls.
- Manage Member and Provider fraud prevention hotline for FWA reporting.
- Enhance existing suite of Client level anti-FWA reports.
- Triage cases and identify items appropriate for escalation to Senior Management
- Represent business on Industry Anti-fraud S14. ubcommittee (CLHIA)
- Represent ClaimSecure with key clients and partners.
- Additional duties as required.

Secondary Responsibilities:

- Scope client needs for Anti-Fraud analytics and complete the work required including the production and review of findings.
- Scope and prepare statistical analysis of health benefit utilization patterns for the business.
- Conduct business impact analysis pertaining to legislative changes and stakeholder initiatives.

**Knowledge, skills and experience**:

- **Bachelor’s degree or Equivalent**: -with **preferred** requirement of medical/ pharmacist and investigations background
- Demonstrated leadership experience (minimum of 5 years)
- Minimum of 3 years’ experience in insurance role or audit experience
- Fraud, waste, and abuse investigation in healthcare experience is an asset.
- Investigation and Audit training is an asset.
- Analytical mindset with strong negotiation skills
- Excellent oral and written communication skills
- Proficient in SQL
- Excellent problem-solving skills
- cellent analyticaExl and organizational skills
- Critical thinking
- Excellent presentation skills

Pay: $80,000.00-$98,000.00 per year

**Benefits**:

- Company events
- Dental care
- Disability insurance
- Employee assistance program
- Extended health care
- Flexible schedule
- Life insurance
- On-site parking
- Paid time off
- RRSP match
- Vision care
- Wellness program
- Work from home

Work Location: Hybrid remote in Mississauga, ON L5B 1M2

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