Fraud Risk Management

Description:

• Investigate situations of fraud and/or abuse with a focus on medical providers and facilities

• Conduct plan member and service provider interviews

• Respond to inquiries and escalations

• Maintain all databases and logs pertaining to Investigations

• Present findings in a variety of settings and to a variety of stakeholders which include but are not limited to: Legal, Health & Dental Claims, Customer Care Center, Plan Sponsors, Account Executives, Clients, etc.

• Prepare and participate in court/complaint cases to resolve investigations

• Research, gather data, prepare and organize documentation for plan sponsors, police and management

• Prepare documentation, such as investigation reports, management briefings, or other communications in a professional and proficient manner

• Identify trends, report on issues and suggest appropriate actions to both internal and external clients

• Perform on-site audits of service providers

• Promote education and awareness to internal and external stakeholders related to fraud prevention

• Identify and partner in the development, implement and maintain processes for the handling of investigations

• Make recommendations for continuous improvement

• Keep up to date on industry trends and schemes impacting benefit plans

Competencies:

• Previous audit / investigation and interviewing experience

• Knowledge of group insurance business and regulatory environment

• Understanding of contractual language, administration guidelines, and provincial and federal legislation applicable to the industry

• Knowledge of medical terminology

• Organizational skills with the ability to develop effective investigative plans

• Communications skills both verbal and written

• Negotiating and influencing skills

• Needs to be able to collaborate well within a team setting

• Analytical skills and critical thinking with attention to accuracy and details

• Decision making skills and innovative thinking

• Advanced computer skills (Word, Excel, Lotus Notes, Adobe, Outlook, PowerPoint)

• Identify processes to mitigate fraud abuse across benefit plans

• For Quebec's candidate: Bilingualism (French, English) required- interactions with English-speaking customers or partners