Claims Investigator

2 weeks ago

Waterloo, Canada Equitable Full time

At Equitable, we realize that your work life is not just about performing a job; it's about being part of a workplace that helps you grow and reach your full potential. Within our friendly and collaborative work environment, we recognize that the key to our growth and success is a dedicated, motivated and client-responsive staff. Join Equitable today.

**Position Title**: Claims Investigator

**Reports To**: Manager, Investigative Claims Unit

**Department**: Group Investigative Claims Unit

**Term**: Permanent Full-Time

**Work Arrangements**: This is a hybrid role. You will work in our office in Waterloo, ON a minimum of two (2) assigned, consecutive days every other week, plus a fifth (5th) assigned day per month. You are welcome to work from the office more than the minimum requirement and there may be some roles that are required to work in our office more than the minimum requirement.

**The Opportunity**: Our Investigative Claims Unit (ICU) team is looking to hire an Investigator to join our growing Group Benefits team As a key member of our team, you’ll identify fraud and abuse situations to minimize financial losses for Equitable and our clients. You will gather intelligence and evidence using data analysis and investigative techniques to validate suspicious situations and make recommendations for action and resolution.

Investigations can take many forms, including reviewing health claim submissions, open source investigations, interviewing plan members and healthcare providers over the phone or in person, and contacting professional associations. A successful investigation has the opportunity to make a big impact. This is a great opportunity to join one of Waterloo’s Top Employers

**What you will do**:

- Review data analytics and other lead sources to identify anomalies or suspicious situations that should be investigated
- Analyze and evaluate potential fraud and abuse situations by reviewing receipts and other supporting documentation submitted as part of the claim process, as well as completing open source investigations
- Complete phone or in person interviews with plan sponsors, plan members, and healthcare providers to obtain additional information as part of the investigative process
- Confirm healthcare provider credentials through correspondence with applicable provider associations
- Develop documented case files with evidence to support recommended actions. (Actions can include delisting providers, recommendations to terminate plan members, making complaints to provider colleges/associations/regulatory bodies, and making referrals to law enforcement)
- Identify and make recommendations for additional risk mitigation measures
- Promote fraud and claims abuse awareness within Equitable
- Work with data analysts to identify scenarios to uncover additional fraud/abuse situations

**What you will bring**:

- A minimum of 3 years experience in fraud investigation or equivalent experience in reviewing, interpreting, and analyzing claims to identify potential areas of fraud or abuse, or similar experience adjudicating health or dental claims
- Strong critical thinking, problem solving and analytical skills with strong attention to detail
- Proven experience in the use of data analytics to identify trends and anomalies
- Polished communication skills with the ability articulate thoughts in a clear and concise manner (both written and verbal) to provide supportable conclusions
- Strong organization and time management skills, with the ability to manage multiple competing priorities and investigations
- Excellent knowledge of group benefits and health and dental claim systems and claim practices
- Strong computer skills including MS Office and the ability to efficiently learn internal systems
- Knowledge of legal processes and evidence collection
- A professional designation in fraud detection, auditing or investigative techniques would be an asset (e.g. Certified Fraud Examiner)

**What’s in it for you**:

- A healthy work-life balance with employee wellness top of mind
- Annual bonus program, annual vacation allowance, and company-paid benefits program
- An additional paid volunteer day each year so you can spend time giving back to the community
- Immediate enrollment in the company’s pension program with employer matching
- Employee resource groups that support an inclusive work environment
- Tuition support and specialized program assistance
- A company subsidized cafeteria with a variety of daily options
- Discounts on company products and services, and access to exclusive employee perks
- Regular EQ Together events focused on company togetherness and collaboration

As part of the recruitment/offer process you will be required to:

- Provide two professional references (minimum one supervisor and above)

LI - Hybrid

To learn more about Equitable, we encourage you to explore our organization.

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