Claims Management Manager (Hybrid)

WHO WE ARE

GreenShieldis a proudly Canadian national non-profit health care and insuranceorganization driven by our mission of Better Health for believe health care is aright not a privilege and we are committed to improving health outcomesadvancing health equity and building a future where every Canadian can reachtheir full health and well-being potential.

Throughour unique integrated payer-provider (payvider) model we offerinsurance administer benefits and pay claims as a payer while offeringhealth care services such as mental health pharmacy telemedicine and chronicdisease management as a provider. As a non-profit social enterprise without shareholders we reinvest our excessearnings to directly support underserved communities. Through GreenShieldCares we positively impacted the health and well-being of over one millionCanadians between 2020 and 2025. Whats driving us now is the commitment to measurably impact an additionalthree million Canadians by 2030 across mental health essential medicinesand chronic disease management through scalable initiatives that delivermeaningful change in pursuit of our mission of Better Health for All.

AtGreenShield our culture is where purpose meets passion and performance. Our teams work as one to delivermeaningful measurable impact for the people and communities we serve.

THEROLE IN A NUTSHELL

Base Salary: CAD $94406.00 - 142069.00

WHO WE ARE

When it comes to health were always looking for ways to push for better. Its why we were founded in the first 1957 our founder pharmacist William Wilkinson witnessed a mother sacrifice her health by foregoing her own medicine to pay for her sick daughters prescription. He knew there had to be a better way. So he introduced North Americas first prepaid drug plan and GreenShield was born as a not-for-profit with a mission to support better health for all Canadians.

We arent just a health and benefits company. Were the only not-for-profit social enterprise that brings worlds of coverage and care together all in one place.

Were noble challengers purposefully building a better way and we need the best people to help us create a more holistic approach that takes care of the mind and body.

Our mission is to create better health for all Canadians and we know that starts with our employees.

THE ROLE IN A NUTSHELL

We are seeking a strategic and analytical Claims Management Manager responsible for building and executing a comprehensive claims oversight framework that enhances financial integrity operational efficiency and member experience. This individual contributor role will serve as a key enterprise resource driving initiatives across auditing anomaly detection and adjudication optimization. The Manager will collaborate with finance pricing fraud automation and product teams to identify cost drivers mitigate risks and ensure claims processes align with organizational objectives and industry benchmarks.

Roles and Responsibilities

1. Claims Oversight and Auditing

• Evaluate existing plan designs for gaps or inefficiencies and recommend enhancements such as Health Spending Accounts (HSAs) maximums and prior authorization criteria.
• Conduct regular audits of plan setup in administrative systems to ensure accurate adjudication logic.
• Partner with internal stakeholders to validate plan configurations and prevent operational errors.

2. Anomaly Detection and Trend Analysis

• Collaborate with Financial Planning & Analytics and pricing teams to develop dashboards and predictive models for identifying emerging cost drivers and utilization patterns.
• Build predictive models for high-cost claims chronic disease prevalence and utilization patterns.
• Develop scenario analysis for catastrophic claims and emerging health risks.
• Analyze Customer Relationship Management and Claims Data Management data to detect unusual claims activity and feed insights into fraud detection and plan design workflows.
• Assess provider-level analytics to uncover patterns contributing to overbilling or inflated costs.

3. Strategic Reporting & Insights

Develop dashboards for claims trend by claim type and provide actionable intelligence to leadership.

Deliver quality insights on cost drivers and emerging risks.

Support executive decision-making with scenario modeling.

4. Root Cause Analysis and Rule Optimization

• Perform deep-dive investigations into transactional data to identify adjudication rule gaps.
• Work with automation and plan build teams to refine rules and improve processing accuracy.
• Recommend system enhancements to reduce manual interventions and improve adjudication speed.

5. Billing and Financial Alignment

• Partner with AR/Billing teams to reconcile member counts commission structures and recoveries.
• Validate that billing accurately reflects plan utilization and enrollment setup.
• Ensure commission recovery processes align with claims adjustments.

6. Fraud Waste and Abuse Collaboration

• Work closely with fraud teams to analyze recovered cases and integrate insights into claims workflows.
• Explore partnerships with external fraud analytics vendors to strengthen detection capabilities.

WHO WERE LOOKING FOR

Were not looking for just anyone. Were looking for a unique individual with a big brain and a big heart who wants to help us create better health for all Canadians.

• Bachelors degree in Finance Mathematics Data Analytics or a related field. Masters degree would be an asset.
• ASA Required. FSA Preferred.
• 5 years of experience in claims management health benefits or insurance operations.
• Strong analytical and investigative skills with the ability to interpret complex data and identify actionable insights.
• Proficiency in data analysis tools and platforms (SQL R Tableau Power BI).
• Experience with auditing anomaly detection and process optimization.
• Ability to collaborate across multiple teams and influence enterprise-level decisions.
• Excellent attention to detail and accuracy with a focus on meeting deadlines.

THE CULTURE
We believe a career should be meaningful. Not just ameans to earn a living. Our culture is one where everyones voice is heard andvalued. Because thats what it takesto create better health for all. We dare to challenge the status quo. And weredriven by people who have challenged theirs. We believe that yourworkplace should empower you to be the best version of yourself. Thats why we provide aplace where you can be inspired challenged and rewarded.

Where your growth means our growth.
Where your voice is heard and valued.
Where your work has purpose. And purpose matters.

We believe our people arecritical to our overall success. Inclusivity makes us a stronger smarter andmore informed organization. Being intentionally inclusive of diversebackgrounds perspectives and experiences will enhance our company culture topositively impact how we support our communities. A career at GreenShield isnt just about personalachievements its about making adifference together.

Heres to Better Health for All!

AFEW MORE DETAILS
Proficiency in English is requiredfor this position. As part of this role you will be required to communicatewith colleagues or customers who use English as their primary language. By requiring English proficiency for thisposition we aim to ensure that our employees can excel in their rolescollaborate and communicate effectively and contribute to the success of ourorganization.

GS supports diversity equity andinclusion in our teams and communities and we value the unique contributionsmade by all. Even if your experience doesnt align perfectly to everyrequirement we invite you to apply. We encourage applications fromall candidates and will accommodate needs under human rights legislationthroughout all stages of the recruitment and selection process. Please let usknow of any accommodation through Information received relating toaccommodation will be addressed confidentially.

Providing this information givesGS consent to use your personal information to assess your suitability forspecific positions future opportunities or for your personnel file. Yourrésumé will be held in strict confidence and will be viewed only by theOrganization. Information may be stored outside of Canada and could be used foraggregate statistical purposes (which uses no personal identification).

AI Usage - GreenShield leverages AI to help produce Job Descriptions and ideate on interview questions. We also leverage AI for interview transcription support.

Required Experience:

Manager