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Senior Investigation Analyst, Dental Analytics

2 months ago

Kitchener, Ontario, Canada Manulife Full time
About the Role

We are seeking a highly skilled and experienced Senior Investigation Analyst, Dental Analytics to join our team. As a key member of our Risk Management Department, you will play a critical role in delivering a broad range of services in support of key operational objectives.

Key Responsibilities
  • Perform risk-based data profiling and analysis to identify trends and outliers in various categories for further review and investigation
  • Lead and support analytics programs; coordinating, assessing, and making decisions on the need for further investigations
  • Assist as needed with the development of new tools and metrics, analytics programs, and collaborations with Data Science partners and external data vendors
  • Take action on analytic program results, including prioritizing reviews for more junior staff, enhancing risk profile assessments, setting investigation frameworks, and collaborating on upstream investigations as needed
  • Respond to challenging situations requiring immediate decisions and/or negotiation
  • Participate in the development of business requirements to identify high-risk providers, members, and suspicious transactions for the continuous development and enhancement of Fraud Data Analytics addressing existing, new, and emerging risks
  • Assist with risk assessments, development of risk mitigating strategies, and delivery of controls to protect the benefit investment of our clients
  • Understand and maintain current knowledge of audit and investigative techniques, tools, software, and technology
  • Provide mentoring to more junior staff in the detection of claims risk through data
  • Assist with risk-related communication materials for Senior Management addressing trends, suggestions for fraud prevention, audits, and controls, taking into consideration regional differences such as privacy, regulatory, criminal, and legal frameworks
  • Deliver presentations on analytics efforts and fraud collaboration initiatives to internal partners
  • Represent Manulife internally and externally on project working groups, industry associations, and initiatives, and carrier meetings, developing key contacts and framing any responses to challenges and risks in claims risk management through analytics
  • Independently respond to difficult situations
What We Are Looking For
  • Knowledge of dental codes and billing practices
  • Dental Assisting or Dental Hygiene experience is an asset
  • Knowledge of Group Benefits
  • Knowledge of the Canadian healthcare environment, service delivery model, and regulation
  • University degree or equivalent work experience
  • CFE designation is an asset
  • Knowledge of fraud and abuse risk, and techniques to manage risk
  • Strong research, problem-solving, and decision-making skills
  • Ability to manage contentious interactions with various stakeholders
  • Excellent oral communication (both phone and face-to-face) and written communication skills
  • Strong data analysis skills with expertise using Excel and other data mining software
  • Demonstrated investigation skills with attention to detail
  • Ability to coach and mentor more junior staff
  • Knowledge of privacy, civil, and criminal legal risks and processes
  • Understanding of provider regulatory colleges and professional associations
  • Understanding of emerging industry threats, associated risks, and impact on benefit plans
  • Demonstrated strong analytical and problem-solving skills
  • Ability to assess analytic programs for effectiveness and make recommendations for enhancements in an evolving environment
  • Ability to apply critical thinking in the assessment, ranking, and solving of complex data reviews and leads
  • Skills and ability to analyze and organize data to support analysis and recommendations for efficiencies in case triage and review processes
  • Exceptional time management and organizational skills, with the ability to manage multiple conflicting priorities in a fast-paced changing environment
  • Good knowledge of compliance issues governing group benefits, provincial laws, and regulations governing insurance, privacy, and the criminal and legal framework
  • Results-oriented, with a proactive approach to seeking solutions and taking action
  • Superior decision-making skills
  • Knowledge of PowerBI, Tableau, PowerApps, and/or SQL, an asset
Key Problems/Challenges
  • Challenged to manage healthcare fraud and abuse issues in a highly unregulated healthcare environment
  • Managing risk on dental transactional-based submissions
  • Need key stakeholder engagement to have a positive impact, including regulatory colleges, associations, law enforcement, data partners, members, and plan sponsors
  • Group Benefits data is not consolidated for a consistent view
  • Internal data is not strategized consistently across the blocks of business, so knowing the challenging internal data landscape and its gaps is key to navigating data programs effectively without bias
  • Data owners, sources, and information technology partners are spread out and inconsistent, requiring an understanding of the internal landscape and managing networks to overcome this hurdle
  • Ability to work with and influence other departments outside of H&D claims, including Legal, Compliance, Marketing, Information Technology, Advanced Analytics, and the Field
  • Interact with individuals outside Manulife as needed and represent Manulife in a positive, professional, and customer-centric manner, while understanding competition risk with other carriers and the nuances of data/program privacy
  • High volume transactions, requiring the ability to prioritize risk to address the highest exposures to Manulife
  • Inherent risk is high with the new electronic trust-based submission channel that includes both regulated and unregulated providers
  • Logistical challenges managing gaps in resourcing in partner organizations
Scope (Dimensions & Organizational Impact)
  • This role delivers risk management services across our dental block of business
  • Will assist with the identification of high-risk members and providers we need to investigate with high financial impact, thus having a significant impact on the profitability of the dental benefit
  • High impact on the ability to mitigate the risk of unfavorable claims experience trending on the dental benefit and positively influence profitability
  • This position will contribute to a positive influence on client retention and enhancement of our reputation by helping to shape our detection programs, identifying risk under our clients' plans, and highlighting potential trends and exposure for further investigation
  • Key representative on analytics initiatives and projects internal and external to ensure risks and controls are considered in project deliverables, addressing gaps by influencing scope and requirements and escalating when appropriate
What We Can Offer You
  • A competitive salary and benefits package
  • A growth trajectory that extends upward and outward, encouraging you to follow your passions and learn new skills
  • A focus on growing your career path with us
  • Flexible work policies and strong work-life balance
  • Professional development and leadership opportunities
Our Commitment to You
  • Values-first culture: We lead with our Values every day and bring them to life together
  • Boundless opportunity: We create opportunities to learn and grow at every stage of your career
  • Boundless opportunity: We invite you to help redefine the future of financial services
  • Delivering the promise of Diversity, Equity, and Inclusion: We foster an inclusive workplace where everyone thrives
  • Championing Corporate Citizenship: We build a business that benefits all stakeholders and has a positive social and environmental impact