Claims Investigator (new)
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Yesterday
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1 Vacancy
Job Summary
The Opportunity: At Equitable we believe great things happen when we work together. Were a Canadian mutual company driven by purpose - putting people first and helping Canadians protect today and prepare for tomorrow. If youre passionate about making a difference and growing your career in an inclusive and collaborative environment wed love to hear from you. Our culture is built on care passion and curiosity. We put people above all else strive to be our best and welcome new ideas to deliver positive outcomes. As a Claims Investigator you will play a critical role in protecting Equitable and its clients by conducting indepth investigations into potential fraud and benefits abuse within Group Benefits claims. You will manage complex cases requiring independent judgment evidence evaluation interviews and detailed documentation. This role offers the opportunity to support highimpact investigative work help prevent financial and regulatory risk and contribute to broader fraudprevention strategies across the one of the regions top employers and be part of something that truly makes a Arrangements: This is a hybrid role. You will work in our office in Waterloo ON a minimum of two (2) assigned consecutive days every other week plus a fifth (5th) assigned day per month. You are welcome to work from the office more than the minimum requirement and there may be some roles that are required to work in our office more than the minimum youll do:Conducting investigations into potential fraud or benefits abuse for cases referred by Investigative analytical findings claim histories data summaries and supporting documentation to determine investigative and conducting telephone and inperson interviews with members providers practitioners and plan medical reports treatment plans billing patterns and regulatory practice standards to assess with internal and external subjectmatter experts on clinical or regulatory detailed case files ensuring objective complete and professional investigative outcomes such as provider delisting plan member termination regulatory complaints or referrals to law and supporting documentation for law enforcement regulators or legal proceedings where financial exposure documenting claim savings and supporting when cases require escalation to Senior Claims Investigators due to complexity legal risk or covert investigative needs. Ensuring adherence to investigative protocols regulatory expectations and internal to inquiries from internal business partners providers and plan members regarding investigative findings or case uptodate knowledge of applicable provincial legislation regulatory requirements and relevant College or professional association in industry committees or sector initiatives to represent the organization and stay informed on emerging fraud fraud and benefitsabuse awareness within the organization by sharing insights trends and best youll bring:Experience conducting investigations into fraud or benefits abuse; a designation such as Certified Fraud Examiner is an with legal processes evidence collection and investigative understanding of fraud schemes collusion indicators and benefits abuse to independently evaluate evidence determine investigative direction and recommend defensible knowledge of health and dental claims provider billing practices medical terminology and group insurance to interpret medical records clinical documentation and regulatory practice communication skills listening verbal written with the ability to explain findings interpersonal skills to manage complex stakeholder interactions conflicts and integrity sound judgment and commitment to organizational prioritization and timemanagement skills to manage multiple sensitive in Microsoft Word Excel Power BI and investigative documentation to work independently and collaboratively within the Investigative Claims Unit (ICU).Adaptability resilience and commitment to continuous in it for you:Career Growth: Regular learning sessions and developmentopportunitiesTotal Rewards: Incentive pay annual salary reviews employer-paid benefits and pensionmatchingTime Away: Competitive vacation plus one paid volunteer day each yearFlexibility: Healthy work-life balance with employee wellness always top of mind complemented by a dress for your day approachAt Equitable were committed to fair pay and an inclusive accessible hiring experience. If you need accommodations or alternative formats at any stage just reach out to us at Were happy to base pay will be based on your skills qualifications experience and addition to your salary this role is eligible for a discretionary annual incentive award tied to business performance plus a wide range of competitive benefits. If youre selected to move forward our Talent Acquisition team will walk you through all the details of our total rewards program so you know exactly whats To: Manager Group Dental Claims and Investigative Claims UnitDepartment: Group Claims Term: Permanent Full-Time
