Analyst role in Hayden Consulting Group's Analytics Lab, providing analytic support on consulting projects. Focus on data - driven problem solving and improving analytic methodologies.
About the role
- Investigation Analyst managing drug claims fraud for Group Benefits. Conducting audits, investigations, and customer interactions with internal and external stakeholders.
Responsibilities
- Perform risk-based data profiling and analysis to identify trends and outliers in various categories for further review and investigation
- Lead and support audit programs; coordinating, assessing, and making decisions on investigations
- Take initiative and independently lead investigations to successful conclusion
- Conduct interviews of plan members, providers of service and others as required
- Create written audits and other correspondence to plan members, providers of service and others
- Engage/interact/consult with various internal contacts such as Customer Service, Legal, Client Relations, Medical Consultants, Regional Group Office, and external stakeholders such as Health Practitioner Regulatory Bodies, Colleges and Associations, and Plan Sponsors
- Lead, support and implement key investigative projects
- Provide technical expertise to internal customers to troubleshoot claims payment, resolve escalated complaints, support issue trends etc.
- Provide oversight of the drug audit program and risk assessment of claim initiatives and client customizations that relate to the drug benefit
- Review and analyze high dollar drug claims and narcotics usage
- Attend client meetings as required
- Attend litigation/arbitration sessions in court if required
Requirements
- 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
- Good presentation and negotiation skills
- Strong analytical, research, problem-solving and decision-making skills
- Effective project management capabilities
- Ability to review and analyze critical data to make formal recommendations for process improvements
- Comfortable speaking with external parties such as pharmacists, health care providers, drug manufacturers, government agencies, plan members and plan sponsors etc.
- Must be able to decipher health industry information and understand how it relates to Group Benefits' plans
- Proven ability to manage/schedule a fluctuating, unpredictable and stressful workload
- Knowledge of Group Benefits
- Knowledge of the Canadian healthcare environment, service delivery model and regulation
- Excellent understanding of third-party claims adjudication as it relates to Pharmacy benefits
- Knowledge of fraud and abuse risk, and techniques to manage risk
- Strong research, problem solving and decision-making skills
- Ability to manage contentious interactions with various stakeholders
- Excellent oral communication (both phone and face to face) and written communication
- Intermediate data analysis skills with expertise using Excel and other data mining software
- Demonstrate investigation skills with attention to detail
- Knowledge of privacy, civil and criminal legal risks and processes
Benefits
- health, dental, mental health, vision, short- and long-term disability, life and AD&D insurance coverage
- adoption/surrogacy and wellness benefits
- employee/family assistance plans
- retirement savings plans (including pension and a global share ownership plan with employer matching contributions)
- financial education and counseling resources
- generous paid time off program
- holidays, vacation, personal, and sick days
- full range of statutory leaves of absence
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