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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 Manager for Fraud Risk Management, the Bilingual Investigative Analyst will work in partnership with Investigators in the identification and investigation of situations involving suspected dishonest, fraudulent and abusive claiming activities pertaining to dental service providers, clinics and plan members.
Applying attention to detail and quick decision-making, the successful candidate will complete several daily tasks, largely focusing on reviewing dental claims for flags representing unusual claiming situations and performing audits. The successful incumbent will collaborate across teams in the prevention and detection of fraud and abuse within the dental landscape.

• Conduct reviews of plan member and service provider claiming behavior to rule out fraud or abuse.
• Using data analysis and audit outcomes, recommend dental providers and clinics for investigation.
• Identify, track and communicate emerging fraud and abuse trends.
• Triage tips and referrals related to inappropriate administration practices of dental providers.
• Provide support to the Investigator on active profiling of dental providers.
• Assist in interviewing plan members and prepare packages for onsite audits.
• Timely collection and documentation of investigative steps and outcomes
• Action and respond to inquiries and escalations.
• Confidently communicate audit findings to a variety of audiences including plan members, service providers and management.
• Assist in the preparation of delist recommendations, regulatory complaints and criminal briefs.
• Promote education and awareness to internal and external stakeholders related to fraud prevention.
• Make recommendations for continuous improvement.
• Keep up to date on trends and schemes impacting benefit plans.