Supervisor, Claim Watch

WHO WE ARE
When it comes to health, we’re always looking for ways to push for better. It’s why we were founded in the first place. In 1957, our founder, pharmacist William Wilkinson, witnessed a mother sacrifice her health by forgoing her own medicine to pay for her sick daughter’s prescription. He knew there had to be a better way. So, he introduced North America’s first prepaid drug plan, and GreenShield was born as a not-for-profit with a mission to support better health for all Canadians.

We aren’t just a health and benefits company. We’re the only not-for-profit social enterprise that brings worlds of coverage and care together, all in one place.
Our mission is to create better health for all Canadians, and we know that starts with our employees.

THE ROLE IN A NUTSHELL

This position, Supervisor Claim Watch, will report to the Manager, Claim Watch. Claim Watch is a program that detects fraudulent activity and protects our plan sponsors' benefit spend. The Claim Watch Supervisor leads a team of specialists in health care benefits fraud investigations, overseeing specialized investigations from small to major cases.

• Lead and support the Claim Watch team by cultivating a positive, collaborative team environment to ensure engagement and motivation in delivering exceptional customer service.
• Supervise, review, audit, and direct fraud investigations to ensure full documentation to withstand legal challenges.
• Act as a liaison with internal and external partners (e.g. Legal and Compliance, Internal Audit) and represent Fraud Operations in cross-functional initiatives.
• Develop and supervise employees, policies, and procedures for fraud detection, prevention, and complex risk mitigation.
• Maintain robust business relationships to resolve ongoing issues and support change management.
• Provide expertise to support Requests for Information (RFI) and Requests for Proposals (RFP).
• Stay informed on developing trends in benefits fraud and industry.
• Oversee recruitment, orientation, training, coaching, performance management, and health and safety of employees.
• Prioritize and manage Investigator involvement (on sites, interviews, etc.).
• Support and maintain Claim Watch AI fraud detection solution.
• Oversee audit processes involving providers, plan members, and medical facilities, ensuring quality and accuracy.
• Prepare and review reports reflecting investigative findings and recommendations for various stakeholders.
• Collaborate with departments, medical providers, and law enforcement to achieve Claim Watch objectives.
• Participate in legal proceedings to resolve investigations.
• Recommend preventative fraud measures and cost containment strategies.
• Train and educate internal departments and Plan Sponsors on the Claim Watch brand.
• Contribute to departmental procedures and processes relating to fraud based on best practices.
• Support Sales in representing the department to current and potential Plan Sponsors / Partners.
• Present at industry conferences to position GreenShield as a leader in fraud prevention.
• Participate in industry working groups and discussions.

WHO WE'RE LOOKING FOR

• A university degree or diploma in business, criminology, law enforcement, or a related discipline.
• Minimum five years’ experience in audit, fraud detection, investigation, or healthcare benefit administration.
• Minimum three years' leadership experience.
• Excellent communication skills for presentations to stakeholders.
• Experience in leading, coaching, and mentoring.
• Identify and implement process improvements and technology changes.
• Strong organizational skills for managing shifting priorities and complex cases.
• Work in an investigative body requiring discretion and confidentiality.
• Develop and monitor fraud strategies in healthcare using analytics.
• Demonstrated leadership in building effective teams.
• Analytical, problem-solving, and decision-making skills.
• Data mining skills to detect fraud patterns in large datasets.
• Planning, organizing, and negotiating skills; manage multiple tasks and deadlines.
• Maintain performance reporting and liaise with business partners.
• Knowledge of relevant legislation and regulations (e.g., PIPEDA) is an asset.
• Advanced computer skills (MS Office and Data Mining Tools).
• Self-confident and adaptable.
• Excellent interpersonal skills for teamwork.
• Strong customer service and relationship management skills.
• Business acumen for setting priorities.
• Some travel within Canada required.

NICE TO HAVE

• Experience in Group health insurance or Benefits Administration.
• Certified Fraud Examiner (CFE).
• Private Investigator license.

THE CULTURE We believe a career should be meaningful, not just a means to earn a living. Our culture values every voice and challenges the status quo. We foster inclusivity of diverse backgrounds, enhancing our company culture and making a difference together.

A FEW MORE DETAILS Proficiency in English required for communication with colleagues or customers. GS supports diversity, equity, and inclusion and invites applications from all candidates, accommodating needs under human rights legislation throughout the recruitment process.