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Pharmacy Profiling Investigator
2 days ago
Job Description :Fraud management is increasingly important to policyholders. In order to serve Sun Life’s clients as industry leaders, Canadian Operations’ Fraud Risk Management area will identify, mitigate and respond to criminal threats using various tools, technologies and strategies. With $2.5 billion paid in drug claims annually, the Investigator investigates pharmacy fraud and abuse detection by using predictive models, pattern analysis, profiling and other intelligence-led strategies. The Pharmacy Profiling Investigator will address the requirements needed to sustain the program and coordinate the leads for investigation on an on-going basis. With the need to continuously adapt and evolve to keep ahead of fraud trends and emerging schemes, the Investigator will also liaise with Sun Life’s drug benefits administrator in the management of pharmacy audits and controls.Reporting to the Manager, Fraud Risk Management (FRM), the Pharmacy Profiling Investigator will work in partnership with other FRM specialists, leaders and areas that support the team and service delivery such as Member Drug Investigators and Analysts, Business Analytics, Pharmacy Consultant, Legal, Compliance, Business Development, Customer Care Centre, and Group Benefits Health & Dental Claims. What will you do?Collaborate with Business Analytics and other key partners in identifying the principles and dataset for predictive models and pattern analysis Develop an action plan to track leads, identify investigative steps, pursue recoveries and deliver results related to pharmacy profilingAct as a subject matter expert for drug related anti-fraud and abuse claim submissions and pharmacy schemesConduct regular assessments on the quality of leads, prioritization of investigations and decisions made on casesRemain up to date on new drugs, products and privacy laws*** Must be able to obtain Reliability Status through the Government of Canada (includes a background check with fingerprinting by the RCMP). ***What do you need to succeed?Pharmacy Technician – Minimum of 3 years full time retail or hospital experienceIn-depth understanding of various drugs and categories, pharmacy drug submission process and audit opportunities, both prepayment and post-paymentProven ability to influence solutions and facilitate cross-departmental teamwork that meets the needs of the business strategyStrong analytical skills and critical thinking with attention to accuracy and detailsExcellent collaboration and team building skillsSolid decision-making skills by understanding and assessing business needs and risksSuperior organizational skills and ability to prioritize initiatives and execute effectivelyAdvanced computer skills (Word, Excel, Lotus Notes, PowerPoint)As this position is posted in several locations, we specify that bilingualism (French, English, both oral and written) is required for Quebec only for the frequent interactions with English and French-speaking colleagues or internal partners across Canada or worldwide.Assets:Registered Pharmacy TechnicianPrevious exposure to group insurance business (products, services, organization, systems, processes) and its regulatory environment across provincesKnowledge of Tableau, Excel or other data visualization toolsPrevious experience auditing the billing practices of pharmaciesStrong knowledge of drug claims submission and processingCFE designation Location & travel:This position is hybrid based in Waterloo or MontrealSome travel to other Sun Life offices, and for education seminars or conferences
