About the role

Claims Verification Analyst role at Manulife ensuring integrity in health and dental claims processes. Involves auditing submissions and addressing fraud risks with stakeholders.

Responsibilities

Reviews audit evidence submissions by plan members to authenticate information, identifies areas of concern, actions issues for resolution, and obtains/requests additional evidence required on suspect claim submissions.
Validates irregular Internet transaction activity through phone call interviews with providers and/or plan members and secures evidence on discrepancies as part of information gathering on suspect claim submission activity.
Requests supporting documentation from plan members and authenticating information, identifying issues and gaps for further review and resolution.
Identifies fraudulent claims, documents and gathers evidence, and supports ongoing management of investigation activity.
Confirms provider’s licensing credentials and legitimate business establishments through Internet searches and by contact with professional associations and colleges.
Actions and resolves issues for successful audit outcomes and escalates key provider control issues to the e-commerce control management team.
Analyzes data to identify anomalies, trends and patterns; and supports testing, and documentation of new risk controls for continuous review of all Internet submission activity.
Supports awareness on e-commerce control and operational workflow issues by providing direction and information to internal Group Benefit departments such as Call Center and various Health and Dental Operation departments.

Knowledge of privacy, civil and criminal legal risks, and processes
Ability to manage contentious interactions with various stakeholders and take control of stressful situations with tact and diplomacy
Excellent oral communication skills and ability to interview service providers, plan members and others for successful audit outcomes
Excellent written communication skills
Resourceful with a proven analytical, problem solving, and troubleshooting background
Proficient in research and quick decision making
Strong organizational skills and the ability to manage multiple conflicting priorities in a fast-paced changing environment as well as adapting to changes are essential
Ability to take-action on ideas, situations, or opportunities before being asked
Ability to be skeptical, probing, creative and aggressive in conducting authentication and investigation activity