Investigative Analyst, Fraud Risk Management

at  Sun Life

You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You’ll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you’ll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

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 Investigative Analyst will work in partnership with Investigators in the identification and investigation of situations involving suspected dishonest and fraudulent claiming activities pertaining to medical service providers and plan members.
Using advanced analytics, innovative thinking and investigative excellence, the successful candidate will complete several daily tasks, largely focusing on service provider and collusion schemes involving medical providers and facilities. They will collaborate across teams in the prevention and detection of criminal activity that can threaten the sustainability of group benefit plans.

• Detect and prevent group benefits fraud and abuse
• Triage tips and referrals related to inappropriate administration practices of service providers, including obtaining witness statements
• Provide support to Investigators by leveraging multiple systems and tools to assist with actively profiling service providers
• Analyze plan member and service provider claim submission patterns to identify trends
• Review claims and determine eligibility
• Respond to inquiries and escalations
• Present findings in a team setting
• Research, conduct social media searches, gather data, prepare and organize documentation for plan sponsors, police and management
• Promote education and awareness to internal and external stakeholders related to fraud prevention
• Make recommendations for continuous improvement
• Timely documentation of investigative steps and outcomes
• Keep up to date on trends and schemes impacting benefit plans