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Investigative Review Specialist II

Job Description

The Investigative Review Specialist (IRS) is a key member of the health and dental team that delivers robust and effective health and dental claims fraud prevention to Great-West Life customers. The main function of the Investigative Review Specialist is to conduct investigations by assessing case information and analytical aspects of the data and then contact providers and clinics to validate services to ensure that claims are free from suspicion of fraud/abuse. The IRS works closely with their leader in determining investigative next steps as well as other members of the teams including data analysts and members of Corporate Security & Investigations.

Taking into consideration the evidence and other information gathered the IRS will propose and execute recommendations regarding resolution of investigations, referrals to Corporate Security & Investigations or recovery. The IRS is responsible for ensuring that case documentation is accurate and complete and will write case reports as needed for their leaders, clients, and senior leadership.

What you will do

Conduct thorough investigations of assigned cases as identified through various detection sources.

The ability to understand and interpret data from various detection sources by working closely with Analysts when required.

Develop and execute the investigative plan to obtain evidence where fraud is suspected by contacting (verbal and/or written) appropriate parties, including plan member, claimant and/or provider.

Document investigative actions and outcomes according to department policy.

Where evidence supports an action, determine and execute the appropriate action according to established protocols.

Consult with other Health and Dental subject matter experts, medical review board and/or consultants, or Legal as warranted by the case.

Write client-facing reports regarding investigative findings and comprehensive reports when cases are referred to Corporate Security & Investigations.

Communicate case information as necessary according to established protocols.

Identify fraud and abuse risks and make recommendations to mitigate future risk.

Maintain accurate methods of record keeping and statistics according to department policy.

Participate on special projects as assigned and may be called upon to lead special projects.

Maintain appropriate professional development.

Living the values of Customer View; Integrity; Partnership; and Communities.

What you will bring

Completion of post-secondary level education (eg: university or college degree/diploma).

Minimum two years related work experience in an adjudicative, investigative, and/or analytical field.

CFE designation would be considered an asset.

A combination of relevant experience and education will be considered.

Strong decision making, problem solving skills and analytical skills.

Proven experience providing excellent customer service.

Excellent ability to communicate, both orally and in writing, in fast-paced and unscripted situations.

Excellent organizational and time management skills; able to handle multiple, simultaneous investigations.

Strong report writing skills.

Strong customer service orientation.

Claims knowledge would be considered an asset.

Understanding of Group Health and Dental Insurance Operations (including legacy systems)/Business knowledge would be an asset.

Demonstrated proficiency using Excel, Word and Access

Be your best at Canada Life- Apply today!

We are Canada Life

Being a part of Canada Life means you have a voice. This is a place where your unique background, perspectives and talents are valued, and shape our future success.

You can be your best here. You’re part of a diverse and inclusive workplace where your career and well-being are championed. You’ll have the opportunity to excel in your way, finding new and better ways to deliver exceptional customer and advisor experiences.

Together, as part of a great team, you’ll deliver on our shared purpose to improve the well-being of Canadians. It’s our driving force. Become part of a strong and successful company that’s trusted by millions of Canadians to do the right thing.

We are one of Canada's top 100 employers!

Canada Life serves the financial security needs of more than 13 million people across Canada, with additional operations in Europe and the United States. As members of the Power Financial Corporation group of companies, we’re one of Canada’s leading insurers with interests in life insurance, health insurance, investment and retirement savings. We offer a broad portfolio of financial and benefit plan solutions for individuals, families, businesses and organizations. 

  

We are committed to providing an inclusive, accessible environment, where all employees and customers feel valued, respected and supported. We are dedicated to building a workforce that reflects the diversity of the communities in which we live, and to creating an environment where every employee has the opportunity to reach their potential. 

  

  

Canada Life would like to thank all applicants, however only those who qualify for an interview will be contacted 

Job Type
Full Time
Salary
N/A
Experience
N/A
Posted
57 days ago

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