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 Senior Claims Fraud Investigator to join the Audit team.
This unique and challenging role will be located at our head office in Burnaby.
Under the direction of the Manager, Fraud Claims Investigations, the Senior Claims Fraud Investigator is responsible for leading and participating investigations of suspected claims fraud and abuse. The Senior Fraud Investigator provides mentorship, consultation and guidance to the fraud investigations team and makes recommendations to management on policy, procedure, and/or performance enhancements.
Duties and Responsibilities:
Conducts thorough routine to complex investigations primarily focused on suspected claims fraud by members and providers across multiple lines of business.
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 manager;
- Conducting comprehensive on-site investigations or desk based audits, or a combination of both;
- Leading, planning, and executing undercover investigations where applicable;
- 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.
Participates in or leads investigative related projects that represent significant loss exposure and/or are highly visible or prioritized by senior management.
Assists the manager in directing/coordinating activities of multiple investigators on complex investigations and providing guidance to investigative staff as needed.
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 manager.
- Minimum 5 years’ experience in fraud investigation; preferably in the healthcare insurance field
- Minimum 3 years’ experience leading a team
- University degree or technical school diploma in a relevant field (Business Administration, Criminology, Law Enforcement, Fraud Examination, Criminal Justice, Health Profession, etc.)
- Certified Fraud Examiner designation is an asset
- Knowledge of the Health Professions Act and Regulations (BC) is an asset
- Effectively communicate with various levels of management, external parties, law enforcement, synthesize complex information, making it relevant, understandable and actionable for internal and external stakeholders
- Experience negotiating investigation settlements
- Strong verbal/written communication and presentation skills, including the ability to communicate with both technical and business teams
- Knowledge of administrative law procedures
- Knowledge of SQL and ACL (running and pairing reports to identify patterns) is an asset
- Advanced Excel (complex data manipulation, statistical analysis, filtering and advanced use of formulas and functions)
- Demonstrate strong analytical and logical thinking and sound judgement skills with the ability to solve complex problems
While we thank all applicants for their interest, only shortlisted candidates will be contacted.