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JOB DESCRIPTION:

Fraud management is increasingly important to policyholders. To serve Sun Life’s clients as industry leaders, Canadian Operations’ Fraud Risk Management area will identify, mitigate and respond to criminal threats using various tools, technologies and strategies.
Reporting to the Manger for Fraud Risk Management (FRM), the Bilingual Dental Investigator will be responsible for fraud detection, prevention, and investigation into extended health care benefits fraud across Canada. Using data analytics, advanced interviewing skills and investigative excellence, the successful candidate will focus on the identification and investigation of situations involving dishonest, fraudulent, and abusive claiming involving dental providers, clinics, and plan members.
Investigations require regular contact with external stakeholders including plan members, dental providers, associations, and colleges. The Investigator will be required to present findings, file regulatory complaints, prepare police cases, and give evidence at regulatory, civil and/or judicial hearings.

• Identify high-risk areas of fraud and abuse in the dental landscape and make recommendations to address control gaps and continuous improvement.
• Investigate situations of fraud and/or abuse with a focus on dental providers, clinics, and plan members.
• Identify trends, report on issues and suggest appropriate actions to internal and external stakeholders.
• Identify and partner in the development and implementation of processes for handling investigations.
• Conduct plan member and provider interviews.
• Perform onsite audits of service providers.
• Action and respond to inquiries and escalations.
• Make quick-thinking and decisive decisions when handling files.
• Maintain all databases and logs pertaining to investigations.
• Prepare documentation, such as investigation reports, management briefings, or other communications in a professional, confident and proficient manner.
• Research, gather data, and present findings in a variety of settings and to a variety of internal and external stakeholders, including clients, service providers, Legal, internal business partners and senior management.
• Prepare for and participate in regulatory, civil and/or judicial hearings to resolve investigations.
• Promote education and awareness to internal and external stakeholders related to fraud prevention.
• Keep up to date on industry trends and schemes impacting benefit plans.