Investigation Consultant, Provider Risk

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**Working Arrangement**

Hybrid

**The opportunity**

The Risk Management Department is a diverse and dynamic team delivering a broad range of services in support of key operational objectives. Our responsibilities include Digital Claims Risk Management, Abuse Management and Monitoring Programs, Fraud Investigations, Technical Support, Analytics, and Claims Experience Management. The effective management of Health and Dental Claims experience is imperative to the continued success of the Group Benefits Operations.

A key focus of the Investigation Consultant, Provider Risk is in the prevention, detection, and investigation of fraud and abuse specific to health care providers. This role will proactively identify risk, champion mitigation strategies, conduct provider investigations and take actions to protect Manulife benefit plans from fraud. This role supports more junior staff with investigations through questions need and supports our claims experience management and the success of our overall Fraud Prevention Program.

The individual in this role will draw on their analytical skills, investigative expertise, customer focus, Group Benefits background, understanding of the Canadian Healthcare environment, regulation, and legislation to figure out ongoing priorities in the delivery of provider controls. The incumbent may conduct external clinic audits and drive the communications required for provider education, fraud awareness and deterrence. The role will collaborate closely externally with industry contacts and law enforcement and internally with Legal, Compliance, Marketing, Customer Service, Client Relations, Ombudsman and the Field.

The Investigation Consultant will understand the risk profile of provider types and influence the decisions of new provider roles accepted through our electronic submission channel so that the integrity of our claims payment process is maintained. In this role the investigate providers and identify those with inappropriate and/or fraudulent business practices taking actions including putting forth recommendations in handling including delisting specific providers from payment across our block. The incumbent must be highly skilled in decision making and negotiating as this position is regularly confronted with potentially contentious situations requiring immediate and appropriate responses.

This role must be a confident communicator with an investigative background, have a technical proficiency with experience using analytical tools, demonstrate leadership skills to mentor junior roles and understand the regulatory and legislative environment across the country in particular as it relates to healthcare and privacy.

**Responsibilities**
- Support and run provider submit risk priorities, redesign the overall audit plan, and complete on-site provider audits taking action on results including developing provider alerts, negotiating overpayments, pursuing criminal, regulatory, and civil actions, dialoguing with professional associations and regulatory colleges, and leading or collaborating on investigations
- May conduct site inspections and on-site audits with or without prior notice at provider locations physically reviewing documents including clinical records, treatment plans, physician referrals and financial records specific to the electronic submissions to Manulife
- Conduct face-to-face or phone interviews of providers, provider office staff, and prescribers in the course of audits or investigations
- Respond to difficult and complicated situations needing immediate decisions and/or resolution
- Own the continued development of the investigative model to handle high risk providers and suspicious transactions and support analytics staff with the continuous development and enhancement of Fraud Data Analytics addressing existing, new, and emerging risk
- Perform risk assessments, develop risk mitigating strategies and deliver 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 junior staff in the detection of deception through data analysis, written and verbal verification requests identifying providers for monitoring and investigation
- Develop provider submit risk related communication materials for plan members, plan sponsors and the provider community including materials addressing fraud prevention, audits, and controls