Claims Verification Analyst

The Claims Verification Analyst is responsible for supporting health and dental claims fraud risk controls by authenticating claim submissions, identifying, and investigating issues for action and resolution, and escalating key control issues to the claims risk management team. 

 

The Claims Verification Analyst will conduct health and dental claims audits through reviewing receipt evidence and supporting documentation, contacting providers and/or plan members to validate submissions, verify provider licensing through internet searches and contact with professional associations and colleges, and follow through on actions from these reviews for successful outcomes.  The auditor will work with our various internal departments, including Technical Services, Customer Service, Investigation Services and H&D Operations for resolution on claims submission issues.

 

The Claims Verification Analyst reports to the Program Manager, Investigation Services, and helps to protect plan sponsors and members from the negative impacts of claims fraud.  This role is focused on risk detection, which is the foundation for our investigation programs and a vital part of claims risk management. 

 

 

Position Responsibilities:

• Reviews audit evidence submissions by plan members to authenticate information, identifies areas of concern, actions issues for resolution, and obtains/requests additional evidence required on suspect claim submissions.

• Validates irregular Internet transaction activity through phone call interviews with providers and/or plan members and secures evidence on discrepancies as part of information gathering on suspect claim submission activity.  Requests supporting documentation from plan members and authenticating information, identifying issues and gaps for further review and resolution.

• Identifies fraudulent claims, documents and gathers evidence, and supports ongoing management of investigation activity

• Confirms provider’s licensing credentials and legitimate business establishments through Internet searches and by contact with professional associations and colleges. Actions and resolves issues for successful audit outcomes and escalates key provider control issues to the e-commerce control management team

• Analyzes data to identify anomalies, trends and patterns; and supports testing, and documentation of new risk controls for continuous review of all Internet submission activity

• Supports awareness on e-commerce control and operational workflow issues by providing direction and information to internal Group Benefit departments such as Call Center and various Health and Dental Operation departments

 

 

Required Qualifications:

• Knowledge of privacy, civil and criminal legal risks, and processes

 

 

Preferred Qualifications:

• Ability to manage contentious interactions with various stakeholders and take control of stressful situations with tact and diplomacy

• Excellent oral communication skills and ability to interview service providers, plan members and others for successful audit outcomes  

• Excellent written communication skills

• Resourceful with a proven analytical, problem solving, and troubleshooting background

• Proficient in research and quick decision making

• Strong organizational skills and the ability to manage multiple conflicting priorities in a fast-paced changing environment as well as adapting to changes are essential   

• Ability to take-action on ideas, situations, or opportunities before being asked

• Ability to be skeptical, probing, creative and aggressive in conducting authentication and investigation activity

 

 

When you join our team:

• We’ll empower you to learn and grow the career you want. 

• We’ll recognize and support you in a flexible environment where well-being and inclusion are more than just words. 

• As part of our global team, we’ll support you in shaping the future you want to see.

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About Manulife and John Hancock

Manulife Financial Corporation is a leading international financial services provider, helping people make their decisions easier and lives better. To learn more about us, visit https://www.manulife.com/en/about/our-story.html.

Manulife is an Equal Opportunity Employer

At Manulife/John Hancock, we embrace our diversity. We strive to attract, develop and retain a workforce that is as diverse as the customers we serve and to foster an inclusive work environment that embraces the strength of cultures and individuals. We are committed to fair recruitment, retention, advancement and compensation, and we administer all of our practices and programs without discrimination on the basis of race, ancestry, place of origin, colour, ethnic origin, citizenship, religion or religious beliefs, creed, sex (including pregnancy and pregnancy-related conditions), sexual orientation, genetic characteristics, veteran status, gender identity, gender expression, age, marital status, family status, disability, or any other ground protected by applicable law.

It is our priority to remove barriers to provide equal access to employment. A Human Resources representative will work with applicants who request a reasonable accommodation during the application process. All information shared during the accommodation request process will be stored and used in a manner that is consistent with applicable laws and Manulife/John Hancock policies. To request a reasonable accommodation in the application process, contact recruitment@manulife.com.

Referenced Salary Location

Waterloo, OntarioHybrid

Salary range is expected to be between

$39,225.00 CAD - $65,375.00 CAD

If you are applying for this role outside of the primary location, please contact recruitment@manulife.com for the salary range for your location. The actual salary will vary depending on local market conditions, geography and relevant job-related factors such as knowledge, skills, qualifications, experience, and education/training. Employees also have the opportunity to participate in incentive programs and earn incentive compensation tied to business and individual performance.

Manulife offers eligible employees a wide array of customizable benefits, including health, dental, mental health, vision, short- and long-term disability, life and AD&D insurance coverage, adoption/surrogacy and wellness benefits, and employee/family assistance plans. We also offer eligible employees various retirement savings plans (including pension and a global share ownership plan with employer matching contributions) and financial education and counseling resources. Our generous paid time off program in Canada includes holidays, vacation, personal, and sick days, and we offer the full range of statutory leaves of absence. If you are applying for this role in the U.S., please contact recruitment@manulife.com for more information about U.S.-specific paid time off provisions.