• Job Description

  Req#: JR23100594

  We are a leading financial services provider committed to making decisions easier and lives better for our customers and colleagues around the world. From our environmental initiatives to our community investments, we lead with values throughout our business. To help us stand out, we help you step up, because when colleagues are healthy, respected and meaningfully challenged, we all thrive. Discover how you can grow your career, make impact and drive real change with our Winning Team today.

  Working Arrangement

  Hybrid

  Job Description

  The Opportunity

  The Risk Management Department is a diverse and dynamic team delivering a broad range of services in support of key operational objectives. Our responsibilities include Digital Claims Risk Management, Abuse Management and Monitoring Programs, Fraud Investigations, Technical Support, Analytics, and Claims Experience Management. The effective management of Health and Dental claims experience is imperative to the success of the Group Benefits Operations.

  A key focus of the Investigation Consultant is on the prevention, detection, and investigation of fraud and abuse specific to pharmaceutical claims. This role will proactively identify risk, champion mitigation strategies, conduct provider investigations and take actions to protect Manulife benefit plans from fraud. This role supports more junior staff with investigations through question support and coaching and contributes to our claims experience management and the success of our overall Fraud Prevention Program.

  The Investigation Consultant will draw on their analytical skills, investigative expertise, customer centric, pharmaceutical background, understanding of the Canadian Healthcare environment, regulation, and legislation to figure out ongoing priorities in the delivery of provider controls. The Investigation Consultant may conduct external clinic audits and drive the communications required for provider education, fraud awareness and deterrence. The role will collaborate closely externally with industry contacts and law enforcement and internally with Legal, Compliance, Marketing, Customer Service, Client Relations, Ombudsman and the Field.

  The Investigation Consultant will understand the risk profile of pharmaceutics and influence the decisions of claim types accepted through our electronic submission channel so that the integrity of our claims payment process is maintained. This role will investigate providers and identify those with inappropriate and/or fraudulent business practices taking actions including putting forth recommendations in handling including delisting specific providers from payment across our block. The Investigation Consultant must be highly skilled in decision making and negotiating as this role will be regularly confronted with potentially contentious situations requiring immediate and appropriate responses.

  This role must be a confident communicator with an investigative and/or pharmaceutical background, have a technical proficiency with experience using analytical tools, demonstrate leadership skills to provide mentoring to more junior roles and understand the regulatory and legislative environment across the country in particular as it relates to healthcare and privacy.

  
  Responsibilities

  • Support and run pharmaceutical risk priorities, redesign the overall audit plan, and implement investigations taking action on results including developing provider alerts, negotiating overpayments, pursuing criminal, regulatory, and civil actions, dialoguing with professional associations and regulatory colleges, and leading or collaborating on investigations
  • May conduct site inspections and on-site audits with or without prior notice at provider locations physically reviewing documents including clinical records, dispensing records, physician referrals and financial records specific to the electronic submissions to Manulife
  • Conduct face-to-face or phone interviews of providers, provider office staff, and prescribers in the course of audits or investigations
  • Respond to difficult and complicated situations requiring immediate decisions and/or negotiation
  • Lead the continued development of the investigative model to handle high risk providers and suspicious transactions and support analytics staff with the continuous development and enhancement of Fraud Data Analytics addressing existing, new, and emerging risk
  • Perform risk assessments, develop risk mitigating strategies and deliver controls to protect the benefit investment of our clients
  • Understand and maintain current knowledge of audit and investigative techniques, tools, software and technology
  • Provide mentoring to more junior staff in the detection of deception through data analysis, written and verbal verification requests identifying providers for monitoring and investigation
  • Develop provider submit risk related communication materials for plan members, plan sponsors and the provider community including materials addressing fraud prevention, audits, and controls taking into consideration regional differences such as privacy, regulatory, criminal, and legal framework
  • Actively participate in sensitive plan sponsor meetings with senior client personnel from legal, benefits, corporate investigations and their audit risk committees leading the discussion and/or delivering presentations
  • Represent Manulife internally and externally on partner meetings, project working groups, industry associations and initiatives, and provider submit carrier meetings developing key contacts and framing any responses to challenges and risks in accepting specific provider groups through the e-claims submissions channel
  • Support the Senior Manager, Fraud Risk Management as needed through program feedback, more junior staff support, and report creation (both analytical and written)
  • Ability to travel is a requirement for this role, including on short notice. Hours worked will need to be flexible based on the clinic or individual providers hours.

  
  How will you create impact?
  
  This role reports to the Senior Manager, Fraud Risk Management, and helps to protect plan sponsors and members from the negative impacts of claims fraud. This role is focused on pharmaceutical risk mitigation, which is a key part of the foundation for our investigation programs and a vital part of claims risk management.

  A key function of the Investigation Consultant role is the investigation of pharmacies, mentoring of more junior staff through question support and investigation mentorship, representation of the overall program to management, and to provide support for reporting and important metrics on an ongoing basis.

  
  What we are looking for

  • Post-Secondary education or equivalent experience - pharmacy technician or pharmacy assistant background would be an asset
  • General understanding of medical terminology, diseases, and drug formularies
  • Comfortable speaking with external parties such as pharmacists, health care providers, drug manufacturers, government agencies, plan members and plan sponsors etc.
  • Excellent understanding of third-party claims adjudication as it relates to Pharmacy benefits
  • Proven understanding of Group Benefits
  • Certified Fraud Examiner (CFE) designation is an asset
  • Knowledge of the Canadian healthcare environment, service delivery model and regulation
  • Proven understanding of fraud and abuse risk, and techniques to handle risk
  • Strong research, problem solving and decision-making skills
  • Ability to lead contentious interactions with various partners
  • Excellent verbal communication (both phone and face to face) and written communication skills
  • Bilingualism or equivalent experience is an asset
  • Sophisticated data analysis skills with expertise using Excel and other data mining software
  • Skills and ability to analyze and prioritize data to support analysis and recommendations
  • Proven investigation skills with attention to detail
  • Sophisticated interviewing skills
  • Ability to coach and mentor more junior staff, acting as a Program Lead within the team
  • Good knowledge of compliance issues governing group benefits, provincial laws and regulations governing insurance, privacy and the criminal and legal framework
  • Understanding of emerging threats, associated risks and impact to benefit plans
  • Exceptional time management and organizational skills. Ability to handle multiple conflicting priorities in a fast-paced changing environment is crucial.

  
  What can we offer?

  • A competitive salary and benefits packages.
  • A growth trajectory that extends upward and outward, encouraging pursuit of passions and learning new skills.
  • A focus on growing your career pathway!
  • Flexible work policies and strong work-life balance.
  • Professional development and leadership opportunities.

  
  Our commitment:

  • Values-first culture!
    We lead with our Values every day and bring them to life together.
  • Boundless opportunity
    We create opportunities to learn and grow at every stage of your career.
  • Continuous innovation
    We invite you to help redefine the future of financial services.
  • Delivering the promise of Diversity, Equity and Inclusion
    We foster an inclusive workplace where everyone thrives.
  • Championing Corporate Citizenship
    We build a business that benefits all partners and has a positive social and environmental impact.

  #Hybrid

  About Manulife and John Hancock

  Manulife Financial Corporation is a leading international financial services group that helps people make their decisions easier and lives better. With our global headquarters in Toronto, Canada, we operate as Manulife across our offices in Asia, Canada, and Europe, and primarily as John Hancock in the United States. We provide financial advice, insurance, and wealth and asset management solutions for individuals, groups and institutions. At the end of 2022, we had more than 40,000 employees, over 116,000 agents, and thousands of distribution partners, serving over 34 million customers. At the end of 2022, we had $1.3 trillion (US$1.0 trillion) in assets under management and administration, including total invested assets of $0.4 trillion (US $0.3 trillion), and segregated funds net assets of $0.3 trillion (US$0.3 trillion). We trade as ‘MFC’ on the Toronto, New York, and the Philippine stock exchanges, and under ‘945’ in Hong Kong.

  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 .

  Salary & Benefits

  The annual base salary for this role is listed below.

  Primary Location

  Waterloo, Ontario

  Salary range is expected to be between

  $55,125.00 CAD - $91,875.00 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.

• About the company

  Manulife Financial Corporation is a Canadian multinational insurance company and financial services provider headquartered in Toronto, Ontario, Canada.

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