Job List

Claims Fraud Investigator

Requisition #2326562
Job LocationCanada-British Columbia-Burnaby
Job StreamHealth Insurance
Job TypePermanent, Full-Time
Number of Positions Open1
Start Date of Employment ASAP
Posting Date04-Jun-2019
Travel RequiredNot Required
Educational RequirementsCollege Diploma
Languages RequiredEnglish
Job Description

Pacific Blue Cross has been British Columbia's leading benefits provider for 75 years. We are an independent, not-for-profit society with strong roots in BC’s health care system. Together with our subsidiary BC Life, we provide health, dental, life, disability and travel coverage to 1 in 3 British Columbians through employee group plans and individual plans.

 

We are fueled by a commitment to keep health care sustainable for all British Columbians. Through our Pacific Blue Cross Health Foundation, we also provide funding to community organizations with a focus on alleviating mental illness and chronic disease. We're interested in finding people who want to make a difference and who will take advantage of every opportunity to build a career with us.

 

Pacific Blue Cross offers an attractive compensation and benefits package, fitness programs, and an onsite gym and cafeteria. Our workplace culture values health and wellness, continuing education, environmental sustainability and giving back to the community.

                      

We are currently recruiting for a Claims Fraud Investigator to join the Audit team.

 

This unique and challenging role will be located at our head office in Burnaby.

 

Job Summary

 

Under the direction of the Manager, Claims Fraud Investigations, the Claims Fraud Investigator is responsible for profiling member and provider claims and conducting comprehensive onsite and desk investigations of suspected claims fraud and abuse including actively pursuing recovery of ineligible funds.

 

Duties and Responsibilities:

 

Conducts thorough routine to complex investigations primarily focused on suspected claims fraud by members and providers across multiple lines of business that include reviewing, interpreting and analyzing claims to identify potential areas of fraudulent claims.

 

Analyzes and evaluates cases in order to develop investigative plans for execution, which may include:

  • Setting objectives, goals, standards and performance expectations for approval by the Assistant Manager;
  • Conducting comprehensive on site investigations or desk based audits, or a combination of both;
  • Conducting in person and/or telephone interviews of witnesses and other involved parties including providers, provider staff, members and any other relevant party.

Gathers information and evidentiary material to support findings that follows the evidence chain of custody procedures.

 

Prepares comprehensive reports for approval by management that include evidence findings, results, and recommended recovery actions and amounts.

 

Informs and discusses the possibility of civil or criminal action with law enforcement agencies and other judicial authorities.

 

Participates in preparation of file documentation for forwarding to law enforcement to assist in the laying of charges under the Criminal Code, and acting as an expert witness for the Crown as necessary.

 

Maintains liaison with regulatory bodies, law enforcement and others to obtain assistance in conducting investigations.

 

Assists with continuous process improvement for investigations.

 

Performs other duties related to department functions as assigned by the Assistant Manager.

  

 

Required Experience

  • Minimum 3 years’ experience in fraud investigation; preferably in the healthcare insurance field

Required Qualifications

  • Certified Fraud Examiner designation and/or Investigation Certificate from the Justice Institute are an asset

Required Competencies

  • Knowledge of current and emerging fraud schemes and investigation practices
  • Advanced Excel (complex data manipulation, statistical analysis, filtering and advanced use of formulas and functions)
  • Knowledge of the Health Professions Act and Regulations (BC) is an asset
  • Knowledge of SQL and ACL (running and pairing reports to identify patterns) is an asset
  • Ability to work on multiple projects, to prioritize, and to meet deadlines
  • Excellent observation and verbal/written communication skills
  • Strong analytical and logical thinking and sound judgement skills with the ability to solve complex problems
  • Ability to effectively plan, prioritize and follow through in a timely manner and with anticipation of potential roadblocks

 

While we thank all applicants for their interest, only shortlisted candidates will be contacted.