Investigative Consultant

Role Summary:

Responsibility for the investigation of any situation involving possible dishonest or fraudulent activities in matters pertaining to Providers, plan members.  Investigations involve health claims.  Identify fraud and abuse, profile abusers, file complaints, file criminal cases, recover money, suggest contractual and administration edits, presentation to clients (internal and external), training and consulting, business expert in health and dental.

Main Accountabilities:
  • Investigate any situation involving possible dishonest or fraudulent activities, member or provider focused
  • Provide assistance to resolve allegations of fraud
  • Conduct interviews and take statements from Providers and patients
  • Collect and safeguard the evidence
  • Maintain all databases and logs pertaining to Investigations
  • Notify the appropriate authorities
  • Responsible for seeking restitution
  • Prepare and participate in court/complaint cases, resolve investigations and protect privacy
  • Assist in the detection and prevention of fraud
  • Identifies trends, report on issues and suggests appropriate actions to both internal and external clients
  • Train health claims staff on ways to prevent fraud
  • Must remain current and up to date on industry trends/education/products/privacy laws etc…
  • Provides expertise on health cases for Senior Management, the Ombudsman, Claims, Business Development and Customer Care Centre
  • Analyses Client specific claims usage reports to detect fraud and/or abuse as requested by Account Executive and Clients
  • Trains and educates internal and external Clients on Sun Life Financials fraud processes
Competencies:
  • Pharmacy Technician – Retail or Hospital
  • Superior knowledge of Pharmacy Benefits specifically (but not limited to) the province of Quebec
  • Bilingual French/English – Exceptional communication skills in both languages – verbal and written
  • Strong knowledge of Health Benefits
  • Strong knowledge of Dental Benefits (an asset)
  • Knowledge of medical terminology
  • Previous Audit / Investigation experience within the Health and Dental Benefits Area is an asset
  • Superior negotiating skills
  • Needs to be able to work in an independent work environment
  • Knowledge and understanding of contractual language, administration guidelines, and provincial and federal legislation applicable to the industry
  • Decision making skills
  • Excellent PC skills (Word, Excel, Power Point, Access)
How To Apply:

Applicants must apply on the following link:
https://sunlifefinancial.taleo.net/careersection/10160/jobdetail.ftl?lang=en&job=CLA04991

 

Persons with disabilities who need accommodation in the application process, or those needing job postings in an alternative format, may e-mail a request to thebrightside@sunlife.com

We thank all applicants for showing an interest in this position. All internal candidates will be contacted regarding the status of their application. If you have any questions, please contact your Recruiting Consultant.