Sr. Investigation Analyst

The Risk Management Department is a diverse and dynamic team delivering a broad range of services in support of key operational objectives. Our responsibilities include Online Claims Risk Management, Abuse Management and Monitoring Programs, Fraud Investigations, Technical Support, Analytics, and Claims Experience Management. The effective management of Health and Dental claims experience is imperative to the success of the Group Benefits Operations.

A key focus of the Sr. Investigation Analyst, Dental Analytics is the prevention, detection, and investigation of fraud and abuse leads for dental claims from all submission channels. This role will proactively identify risk, champion detection strategies, assess the effectiveness of analytics programs and take actions to improve our ability to protect Manulife benefit plans from fraud. This role contributes to our claims experience management and the success of our overall Fraud Prevention Program.

Responsibilities

• Perform risk-based data profiling and analysis to identify trends and outliers in various categories for further review and investigation
• Lead and support analytics programs; coordinating, assessing, and making decisions on the need for further investigations
• Assist as needed with the development of new tools and metrics, analytics programs and collaborations with Data Science partners and external data vendors.
• Take action on analytic program results including prioritizing reviews for more junior staff, enhancing risk profile assessments, setting investigation framework resulting from the alerts, dialoguing with professional associations and regulatory colleges, industry peers and vendors, and collaborating on upstream investigations as needed.
• Respond to challenging situations requiring immediate decisions and/or negotiation
• Participate in the development of the business requirements to identify high-risk providers, members, and suspicious transactions for the continuous development and enhancement of Fraud Data Analytics addressing existing, new, and emerging risks.
• Assist with risk assessments, development of risk mitigating strategies and delivery of controls to protect the benefit investment of our clients
• Understand and maintain current knowledge of audit and investigative techniques, tools, software, and technology
• Provide mentoring to more junior staff in the detection of claims risk through data
• Assist with risk-related communication materials for Senior Management addressing trends, suggestions for fraud prevention, audits, and controls taking into consideration regional differences such as privacy, regulatory, criminal, and legal framework
• Deliver presentations on analytics efforts and fraud collaboration initiatives to internal partners.
• Represent Manulife internally and externally on project working groups, industry associations and initiatives, and carrier meetings developing key contacts and framing any responses to challenges and risks in claims risk management through analytics
• Independently respond to difficult situations

How will you create impact?

The Sr. Investigation Analyst, Dental Analytics will draw on their in-depth analytical skills, clinical knowledge of dental codes and billing practices, investigative expertise, customer focus and understanding of the Canadian Healthcare environment, regulation, and legislation to determine the ongoing priorities in the delivery of analytics controls and will conduct regular reviews of programs to identify trends and opportunities for improvement. The Sr. Investigation Analyst, Dental Analytics is responsible for helping to facilitate communication between data science teams and business partners to identify and drive the programs to suit business needs and communications required for fraud awareness, detection, and deterrence. The role may liaise externally with industry contacts and vendors, and internally with Legal, Compliance, Advanced Analytics, Marketing, Customer Service, Client Relations, Ombudsman and the Field as needed.

The Sr. Investigation Analyst, Dental Analytics will understand the risk profile of all submission types and influence the decisions of new controls and analytics protecting all channels and claims systems so that the integrity of our claims payment process is maintained. This role will investigate data anomalies and business rules and identify parties with inappropriate and/or fraudulent claims for investigation including putting forth recommendations in handling utilizing a strong investigation background. The Sr. Investigation Analyst, Dental Analytics must be highly skilled in decision-making and negotiating as this role will facilitate communication between technical and business partners, as well as outside vendors and industry peers.

This role must be a confident communicator with a strong investigative background, have a technical aptitude with knowledge of the Canadian dental industry, demonstrate leadership skills to provide mentoring to more junior roles and understand the regulatory and legislative environment across the country as it relates to healthcare and privacy.

This role reports to the Sr. Manager, Fraud Risk Management within Health and Dental, GB Operations.

What motivates you?

• You obsess about customers, listen, engage and act for their benefit.
• You think big, with curiosity to discover ways to use your agile approach and enable business outcomes.
• You thrive in teams and enjoy getting things done together.
• You take ownership and build solutions, focusing on what matters.
• You do what is right, work with integrity and speak up.
• You share your humanity, helping us build a diverse and inclusive work environment for everyone

What we are looking for

• Knowledge of dental codes and billing practices
• Dental Assisting or Dental Hygiene experience is an asset
• Knowledge of Group Benefits
• Knowledge of the Canadian healthcare environment, service delivery model and regulation
• University degree or equivalent work experience
• CFE designation is an asset
• Knowledge of fraud and abuse risk, and techniques to manage risk
• Strong research, problem-solving and decision-making skills
• Ability to manage contentious interactions with various stakeholders
• Excellent oral communication (both phone and face-to-face) and written communication skills
• Strong data analysis skills with expertise using Excel and other data mining software
• Demonstrated investigation skills with attention to detail
• Ability to coach and mentor more junior staff
• Knowledge of privacy, civil and criminal legal risks and processes
• Understanding of provider regulatory colleges and professional associations
• Understanding of emerging industry threats, associated risks, and impact on benefit plans
• Demonstrated strong analytical and problem-solving skills
• Ability to assess analytic programs for effectiveness and make recommendations for enhancements in an evolving environment
• Ability to apply critical thinking in the assessment, ranking, and solving of complex data reviews and leads.
• Skills and ability to analyze and organize data to support analysis and recommendations for efficiencies in case triage and review processes
• Exceptional time management and organizational skills. The ability to manage multiple conflicting priorities in a fast-paced changing environment is essential.
• Good knowledge of compliance issues governing group benefits, provincial laws and regulations governing insurance, privacy, and the criminal and legal framework
• Results-oriented. Proactively seeks solutions and takes action
• Superior decision-making skills.
• Knowledge of PowerBI, Tableau, PowerApps, and/or SQL, an asset.

Key Problems/Challenges:

• Challenged to manage healthcare fraud and abuse issues in a highly unregulated healthcare environment
• Managing risk on dental transactional-based submissions
• Need key stakeholder engagement to have a positive impact i.e., regulatory colleges, associations, law enforcement, data partners, members, and plan sponsors
• Group Benefits data is not consolidated for a consistent view
• Internal data is not strategized consistently across the blocks of business, so knowing the challenging internal data landscape and its gaps is key to navigating data programs effectively without bias
• Data owners, sources and information technology partners are spread out and inconsistent. Understanding the internal landscape and managing networks is required to overcome this hurdle.
• Ability to work with and influence other departments outside of H&D claims including Legal, Compliance, Marketing, Information Technology, Advanced Analytics and the Field
• Interact with individuals outside Manulife as needed and represent Manulife in a positive, professional and customer-centric manner, while understanding competition risk with other carriers and the nuances of data/program privacy.
• High volume transactions. Ability to prioritize the risk so that the highest exposures to Manulife are addressed
• Inherent risk is high with the new electronic trust-based submission channel that includes both regulated and unregulated providers
• Logistical challenges managing gaps in resourcing in partner organizations

Scope (Dimensions & Organizational Impact):

• This role delivers risk management services across our dental block of business
• Will assist with the identification of high-risk members and providers we need to investigate with high financial impact thus having a significant impact on the profitability of the dental benefit.
• High impact on the ability to mitigate the risk of unfavourable claims experience trending on the dental benefit and positively influence profitability
• This position will contribute to a positive influence on client retention and enhancement of our reputation by helping to shape our detection programs, identifying risk under our clients’ plans, and highlighting potential trends and exposure for further investigation.
• Key representative on analytics initiatives and projects internal and external to ensure risks and controls are considered in project deliverables. Address gaps by influencing scope and requirements and escalating when appropriate

What can we offer you?

• A competitive salary and benefits package.
• A growth trajectory that extends upward and outward, encouraging you to follow your passions and learn new skills.
• A focus on growing your career path with us.
• Flexible work policies and strong work-life balance.
• Professional development and leadership opportunities.

Our commitment to you

• Values-first culture: We lead with our Values every day and bring them to life together.
• Boundless opportunity: We create opportunities to learn and grow at every stage of your career.
• Boundless opportunity: We invite you to help redefine the future of financial services.
• Delivering the promise of Diversity, Equity and Inclusion: We foster an inclusive workplace where everyone thrives.
• Championing Corporate Citizenship: We build a business that benefits all stakeholders and has a positive social and environmental impact.

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About Manulife and John Hancock

Manulife Financial Corporation is a leading international financial services provider, helping people make their decisions easier and lives better. To learn more about us, visit [https://www.manulife.com/en/about/our-story.html>.

Manulife is an Equal Opportunity Employer

At Manulife/John Hancock, we embrace our diversity. We strive to attract, develop and retain a workforce that is as diverse as the customers we serve and to foster an inclusive work environment that embraces the strength of cultures and individuals. We are committed to fair recruitment, retention, advancement and compensation, and we administer all of our practices and programs without discrimination on the basis of race, ancestry, place of origin, colour, ethnic origin, citizenship, religion or religious beliefs, creed, sex (including pregnancy and pregnancy-related conditions), sexual orientation, genetic characteristics, veteran status, gender identity, gender expression, age, marital status, family status, disability, or any other ground protected by applicable law.

It is our priority to remove barriers to provide equal access to employment. A Human Resources representative will work with applicants who request a reasonable accommodation during the application process. All information shared during the accommodation request process will be stored and used in a manner that is consistent with applicable laws and Manulife/John Hancock policies. To request a reasonable accommodation in the application process, contact recruitment@manulife.com.

Primary Location

Waterloo, Ontario

Working Arrangement

Hybrid

Salary range is expected to be between

$49,575.00 CAD - $82,625.00 CAD

If you are applying for this role outside of the primary location, please contact recruitment@manulife.com for the salary range for your location. The actual salary will vary depending on local market conditions, geography and relevant job-related factors such as knowledge, skills, qualifications, experience, and education/training. Employees also have the opportunity to participate in incentive programs and earn incentive compensation tied to business and individual performance.

Manulife offers eligible employees a wide array of customizable benefits, including health, dental, mental health, vision, short- and long-term disability, life and AD&D insurance coverage, adoption/surrogacy and wellness benefits, and employee/family assistance plans. We also offer eligible employees various retirement savings plans (including pension and a global share ownership plan with employer matching contributions) and financial education and counseling resources. Our generous paid time off program in Canada includes holidays, vacation, personal, and sick days, and we offer the full range of statutory leaves of absence. If you are applying for this role in the U.S., please contact recruitment@manulife.com for more information about U.S.-specific paid time off provisions.