Manager, Investigative Claims Unit

Position Title: Manager, Investigative Claims Unit
Reports To: Director, Group Health and Dental Claims
Department: Group Claims
Term: Permanent Full-Time


Work 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 requirement.

 
The Opportunity: We are looking for a Manager, Investigative Claims Unit (ICU) to join our Group Claims team!

This role is responsible for the Investigative Claims Unit (ICU). The ICU team identifies, investigates and addresses fraud and abuse situations within the Group Insurance division through the completion of data analysis, investigations, and taking appropriate action. Actions can include delisting a provider so future claims will not be accepted, submitting regulatory or criminal complaints, and working with plan sponsors to terminate coverage for applicable plan members. 

Now is an exciting time to join one of the Waterloo Area’s and Southwestern Ontario’s Top Employers for 2024!

What you will be doing:

• Provide leadership to the ICU team to identify and investigate suspicious situations. This includes interviews with plan sponsors, plan members, providers and facility owners to obtain missing information, and conducting audits. Accompanying investigators on external interviews may also be required.
• Drive operational processes to utilize data for fraud analytics
• Facilitate the Fraud Strategy Working Group, including representation from EVP Group Insurance, VP Group Claims, Director Group Health and Dental Claims, EVP, Chief Legal Officer, AVP & Chief Compliance Officer to discuss Equitable processes and guidelines when uncovering fraud, and how to best mitigate risk for the Company and our clients
• Manage and implement projects and workflow to achieve the EQ Strategy for Fraud Management 
• Co-ordinate deliverables and timelines for data analysts that support the ICU 
• Ensure documented rationale is in place and appropriate evidence is recorded to support recommendations to de-list facilities and practitioners
• Coach and mentor ICU investigators and analysts
• Represent EQ in CLHIA anti-fraud committees and working groups

What you will bring:

• Post secondary education or equivalent combination of education and work experience
• A minimum of 10 years experience in fraud investigation or equivalent experience in reviewing, interpreting and analyzing data to identify potential areas of fraud or abuse. A professional designation in fraud detection, auditing or investigative techniques is an asset (e.g. Certified Fraud Examiner)
• Proven successful management of a professional team
• Strong Group Insurance background, including group health and dental benefits knowledge and applicable current legislation is an asset
• Superior interpersonal skills to manage relationships with internal and external clients, partners and colleagues
• Excellent investigative and interviewing skills including conflict management and negotiation skills. Ability to deal with complex and contentious issues
• Organization, communication, analytical, interpersonal, motivational, and management skills are essential
• Listening and persuasion skills along with attention to detail and memory skills
• Good understanding of budget and budget management
• Excellent leadership, mentoring and coaching abilities
• Strong analytical ability, decision making ability, innovative and able to meet conflicting and challenging deadlines
• Excellent computer skills including Office 365 and ability to learn internal applications
• Expertise in open-source investigations and evidence gathering as per court requirements
• Familiarity with the criminal code of Canada
• Presentation skills and subject matter expertise are required to deliver fraud prevention training internally and to our external stakeholders
• Law enforcement experience is an asset

What’s in it for you:

• A healthy work-life balance with employee wellness top of mind
• Annual bonus program, annual vacation allowance, and company-paid benefits program
• An additional paid volunteer day each year so you can spend time giving back to the community
• Immediate enrollment in the company’s pension program with employer matching
• Employee resource groups that support an inclusive work environment
• Tuition support and specialized program assistance
• An onsite, full-service cafeteria with a variety of daily options
• Discounts on company products and services, and access to exclusive employee perks
• Regular EQ Together events focused on company togetherness and collaboration
  
  

As part of the recruitment/offer process you will be required to:

• Provide two professional references (minimum one supervisor and above)

This role is open due to an existing vacancy.

To learn more about Equitable, we encourage you to explore our organization.

At Equitable, we are committed to providing equal access to employment opportunities across our organization. Please contact our HR team at careers@equitable.ca if you would like to receive our job postings in an alternative format or require an accommodation with the application process.

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