Job Opportunities Title:
Senior Claims Investigator Job Posting

Post Date
10/5/2017

Expiration Date
12/31/2017

Details:
- Conduct investigations with a focus on thoroughness and quality, with attention to detail, timeliness and cost control on all types of health and dental claims for fraud and abuse (within published service standards)
- Interview plan sponsors, plan members, providers and facility owners by telephone and in person to obtain missing information, conduct audits, and thoroughly investigate cases or alleged fraud
- Assists in the development and training of the claim staff to make them aware of the red flags they should look for on the claims they process
- Responding to client and plan member inquiries regarding the investigation process and specific claims details, and deal with upset clients
-Prepare police briefs when required
- Perform onsite visits with practitioners and facilities
Contribute to regulatory and criminal complaint process
- Review claims with medical and dental consultants
- Work closely with the health and dental claims staff and managers to effectively manage claim investigations
- Contribute to the continuous process improvement and identify improvement opportunities within SIU and Group Benefits.

Qualifications:
- Excellent investigative and interview skills, including conflict management and negotiation skills.
- Ability to deal with complex and contentious issues, including escalated calls from Health and Dental claim departments and Junior investigator
- Expertise in open source investigations and evidence gathering, as per court requirements
- Familiarity with the criminal code of Canada
- Presentation skills and subject matter expertise
- Excellent written and verbal communication skills
- Strong interpersonal skills as you work extensively with internal cross functional departments, and externally with vendors, customers and providers.
- Exceptional interview skills, with the ability to keep control of the conversation and change tactics as needed
- Excellent knowledge of group benefits and health and dental claims systems and claim practices
- Minimum 2 years’ experience in fraud Investigations
- Participate in the development of Best Practice
- Investigations related to Health and Dental claims
- Ability to manage/schedule fluctuating and unpredictable workload to reach established service standards
- Organization skills
- Ability to establish strong networking skills
- Ability to work independently
- Expertise with Microsoft Office Access and excel, including pivot tables
- CFE (Certified Fraud Examiner) or agreement to obtain within 2 years of employment

Employer:
Equitable Life of Canada
Contact:
Jeff Smith

Address:
1 Westmount Road North

Work Phone:
519-904-8549

Email:
careers@equitable.ca

Website:
https://canr52.dayforcehcm.com/CandidatePortal/en-US/equitable/Posting/View/337?src=email