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Investigator

SUN LIFE FINANCIAL

This is a Full-time position in Toronto, ON posted August 31, 2017.

Role Summary: Fraud management is increasingly important to policyholders. In order to serve Sun Life’s clients as industry leaders, the Canadian Operations’ Fraud Risk Management (FRM) area will identify, mitigate and respond to criminal threats using various tools, technologies and strategies. Reporting to the Fraud Risk Management (FRM) Member Investigations Manager, the Investigator will investigate situations involving possible dishonest, fraudulent, and/or abusive activities related to Group Benefits claims, including Disability. The role includes investigating cases of fraud and abuse, filing regulatory complaints, preparing police cases, conducting interviews and timely communication with various internal and external stakeholders. The role requires an incumbent who is enthusiastic and thrives in a fast paced and changing work environment.
Main Accountabilities:

  • Conduct a formal inquiry when fraudulent Medical, Dental, or Disability claims, or related dishonest activity, is suspected
  • Conduct interviews and take statements from claimants, plan sponsors, service providers, attending physicians, and other third parties
  • Assist in coordinating efforts between FRM and Disability Claims to identify and investigate claims fraud and plan abuse
  • Conduct policy, certificate and provider reviews
  • Maintain case documentation and evidence
  • Prepare/contribute to reports for trends analysis
  • Identify fraud trends and support data analytics solutions to mitigate the newly identified risk
  • Provide assistance to resolve allegations of fraud
  • Provide investigative expertise and related reporting on cases to FRM management, the Ombudsman, Disability Claims, Business Development, Customer Care Centre, and other pertinent internal and external stakeholders
  • Prepare and file regulatory complaints
  • Prepare and support police cases to law enforcement
  • Assist in the detection and prevention of fraud and abuse
  • Train internal and external stakeholders on ways to prevent fraud and abuse
  • Remain current and up to date on industry trends/education/products/privacy laws/etc.

Competencies:

  • Strong knowledge of Group Benefits products, including Disability benefits
  • Interviewing skills
  • Research and analysis
  • Knowledge of medical terminology
  • Previous Investigation experience within the Health and Dental Benefits area and/or within the medical industry is an asset
  • Exceptional communications skills both verbal and written
  • Knowledge and understanding of contractual language, administration guidelines, and provincial and federal legislation applicable to the industry
  • Strong decision making and negotiation skills
  • Excellent PC skills (Word, Excel, Power Point, Access)
  • Direct or indirect experience as a medical practitioner is an asset
  • Experience in Disability claims, including supporting case management decisions is an asset
  • Bilingual (English & French) is an asset
  • University degree is an asset

Location & Travel:

  • This position will be in Waterloo
  • Some travel will be required

*LI-SW2