Investigator

Job Description

Fraud management is increasingly important to policy holders. 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.

Reporting to the Manager for Fraud Risk Management (FRM), the Investigator will be responsible for detecting, investigating, and preventing collusion schemes impacting the Canadian Group Benefits business.

The incumbent will work closely with stakeholders; specifically medical service providers, Account Executives, Plan Sponsors and Plan Members, to deliver timely updates and outcomes.

Using data analytics, advanced interviewing skills and investigative excellence, the successful candidate will largely focus on collusion schemes involving medical providers, facilities, and Plan Members.

What will you do?

• 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
• 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, etc.
• Prepare and participate in court / complaint cases, including arbitration hearings, 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 desk and site audits of service providers and medical facilities
• Promote education and awareness to internal and external stakeholders related to fraud prevention
• Identify and partner to develop, implement and maintain processes for the handling of investigations

What do you need to succeed?

• 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
• Superior organizational skills with the ability to develop and execute effective investigative plans
• Ability to deliver case presentations and exceptional verbal and written communications skills
• Strong negotiating and influencing skills
• Needs to be able to collaborate well within a team setting
• Strong analytical skills and critical thinking with attention to accuracy and details
• Solid decision-making skills and innovative thinking
• Ability to collect, evaluate and analyze open source intelligence
• Identify processes to mitigate fraud and / or abuse across benefit plans
• 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.

Unique Notes :

• This position can be based in Montreal, Waterloo or Toronto with occasional travel.
• The candidate retained for this role will have to go through a special security clearance from the Royal Canadian Mountain Police.

To see if you are eligible for this clearance, please review the Government of Canada website.

What's in it for you?

• Supportive working environment, culture of collaboration, high performance teams
• We’re committed to creating an inclusive and respectful environment. Our goal is to make sure all our employees have the chance to live up to their full potential
• Our unique Sabbatical Program gives you the opportunity to take up to 6 weeks off, every five years.
• We’re proud to be recognized as a company with a 2023 Most Trusted Executive team by Great Place to Work® Canada
• Sun Life ranked one of the 2023 Global 100 Most Sustainable Corporations in the World on the Corporate Knights’ 2023
11 days ago