Claims Fraud Investigator

6 months ago

Burnaby, Canada Pacific Blue Cross Full time

**About Pacific Blue Cross**

Pacific Blue Cross (PBC) has been British Columbia's leading benefits provider for over 80 years. We are an independent, not-for-profit society with strong roots in BC’s health care system. We provide health, dental, life, disability, and travel coverage to 1 in 3 British Columbians through employee group plans and individual plans.

We are fueled by a commitment to keep health care sustainable for all British Columbians. Through our PBC Health Foundation, we fund projects that improve health outcomes directly related to mental health and wellbeing as well as the prevention and/or management of chronic disease. We are interested in finding people who want to make a difference and who are looking to grow their career with us.

**Perks**
- Work-life balance with flexible working hours of 7.5 hours per day, Monday to Friday (i.e., 37.5 hours per week).
- Paid vacation starts at 4 weeks per year, and increases with years of service.
- Hybrid work environment (i.e., a combination of work from office and work from home days).
- Generous benefits, including extended health, dental, and life insurance; depending on the plan that you choose, these benefit premiums can be 100% paid by PBC.
- Company pension contributions after 1 year of service.
- Education allowance to expand your knowledge and develop your skills.
- Onsite gym, cafeteria, and access to virtual doctors/counsellors 24/7 via our Employee Family Assistance Program

**About the Position**
- We are searching for a permanent _Claims Fraud Investigator _to join our Claims Fraud and Abuse Investigations team.
- PBCs compensation offerings are grounded in a pay-for-performance philosophy that recognizes exceptional individual and team performance. The typical hiring range for this position is $60,000- $80,000 per year; the base pay offered is based on market and may vary depending on job-related knowledge, skills, experience, and internal equity. The starting salary will be determined based on a combination of skills, education, and experience.

If you’re someone with a passion for investigating suspected claims fraud and insurance abuse and are wanting to take on a great career opportunity with a local not-for-profit health insurance provider by working with internal and external stakeholders, we want to hear from you.

Your skills in profiling member and provider claims and conducting comprehensive desk audits and investigations will help Pacific Blue Cross be able to provide sustainable healthcare.

We offer an attractive compensation and benefits package and work-life balance. Our workplace culture values health and wellness, diversity and equality, continuing education, environmental sustainability and giving back to the community.

**Key Ways This Position Makes an Impact**

The Claims Fraud Investigator works with the team to review member and provider claims of suspected claims fraud and insurance abuse and actively pursue recovery of ineligible funds.

This role analyzes cases, work with large sets of claims data and develops investigative plans to conduct investigations and/or desk audits, and occasionally in person.

In this role, you would gather information and evidentiary material to support findings that follow the principles of administrative law.

You would prepare comprehensive reports that include evidence findings, results, and recommended recovery actions and amounts.

This role would help with putting together file documentation for referral to regulatory, civil or criminal consideration.

**Key Experiences You Bring to This Role**
- Minimum 3 years’ experience in fraud investigation or equivalent experience in reviewing, interpreting and analyzing claims to identify potential areas of fraudulent or insurance abuse claims; preferably in the healthcare insurance field and with a preference to working in health care, benefits, or insurance
- University degree or technical diploma in a relevant field.
- Certified Fraud Examiner designation and/or Investigation Certificate from the Justice Institute is preferred.

Together we can create a healthier British Columbia through teamwork, exceptional service and accountability that will help improve sustainable healthcare.

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