Job List

Manager, Claims Fraud Investigations

Requisition #2328026
Job LocationCanada-British Columbia-Burnaby
Job StreamManagement
Job TypePermanent, Full-Time
Number of Positions Open1
Start Date of Employment ASAP
Posting Date29-Jul-2019
Travel RequiredNot Required
Educational RequirementsBachelors Degree
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 Manager, Claims Fraud Investigations 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 Executive Director, the Manager is responsible for reducing fraud losses by efficiently and effectively investigating allegations of member and/or provider claims fraud. The successful candidate will provide mentorship, oversight and guidance to the fraud investigations team and make recommendations to senior management on policy, procedure, and performance enhancements. The Manager will assist the Executive Director in the development, execution, and reporting of strategic goals and objectives, and operational plans.

 

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

 

Key Accountabilities:

 

Leadership, Employee Development and Performance Coaching

 

Provides leadership to department employees to promote motivation and teamwork and to ensure the provision of a skilled workforce by:

  • setting clear performance objectives for each team member, monitoring skills and abilities, providing informal coaching and mentoring support;
  • conducting regular formal coaching sessions to review individual performance, conducting formal performance reviews to identify strengths and challenges;
  • identifying team member strengths and challenges, overseeing training and career development activities for the department;
  • conducting regular department meetings to facilitate open communication.

Works with Executive Director to maintain effective staffing levels of the Fraud Investigation department through effective workforce planning, including hiring of staff as required.

 

Monitors attendance and performance of employees, and addresses concerns. Participates in the progressive discipline process as required.

 

Advocates and drives change within the department as necessary, ensures effective communication, reward and recognition, and manages resistance to change as appropriate.  

 

Manages, motivates and provides support to staff to meet performance and strategic goals.

 

Department and Interdepartmental Planning and Effectiveness

 

Works with Executive Director to create the department budget, monitor it regularly, creates and implements strategies to address gaps.

 

Partners with managers and other internal and external stakeholders to ensure effective cross-departmental planning, communication and implementation of plans in achievement of PBC’s overall strategic plan.

 

Analyzes and supervises fraud investigation activities.

 

Conducts 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 and/or approve investigative plans for execution by the fraud investigations team, which may include:

  • Setting objectives, goals, standards and performance expectations;
  • 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 and/or approves comprehensive reports that include evidence findings, results, and recommended recovery actions and amounts.

 

Leads or participates in investigative related projects that represent significant loss exposure and/or are highly visible or prioritized by upper management.

 

Directs and coordinates activities of multiple investigators on complex investigations and providing guidance to the investigations team as necessary,

 

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

 

Participates in the preparation of the report and 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,

 

Develops and maintains policies, procedures and workflow in the Fraud Investigation department to meet short and long term strategic goals.

 

Performs other duties related to department functions.

 

Required Experience

  • Minimum 5 years’ experience in fraud investigation; preferably in the healthcare insurance field
  • Minimum 5 years’ leadership experience in a related role
  • Working knowledge of the Health Professions Act and Regulations (BC) is an asset

Required Qualifications

  • University degree or technical school diploma in a relevant field (Business Administration, Criminology, Law Enforcement, Fraud Examination, Criminal Justice, Health Profession, etc.), including or supplemented by courses in leadership or supervision

Required Competencies 

  • Adaptability to changing priorities
  • Ability to effectively communicate to various levels of management, external parties, law enforcement, synthesize complex information, making it relevant, understandable and actionable for stakeholders
  • Demonstrated 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
  • Strong verbal/written communication and presentation skills, including the ability to communicate with both technical and business teams
  • Exceptional relationship building skills
  • Strong analytical, communication, organization and decision making-skills
  • Knowledge of SQL and ACL (running and pairing reports to identify patterns) is an asset
  • Excel (complex data manipulation, statistical analysis, filtering and advanced use of formulas and functions)

 

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