Claims Fraud Analyst

Job Description

We are looking for detail-oriented, analytical, and proactive Claim Fraud Analysts to join our fraud detection and prevention team. As part of our dynamic team, you'll have the opportunity to make a real impact by helping prevent fraudulent activities and ensuring that our clients' claims are handled with the highest level of integrity. Join us in our mission to protect and serve our clients while advancing your career in a fast paced and supportive environment.

Role and Responsibilities

• Analyze claims for signs of fraud or suspicious activity.
• Conduct thorough investigations to verify the legitimacy of claims, including interviews, evidence collection, and surveillance.
• Identify patterns of fraud, track emerging trends, and work to uncover fraudulent schemes.
• Review claim data to spot anomalies or red flags.
• Utilize fraud detection tools, software, and databases to assist in identifying fraudulent claims.
• Maintain accurate records of findings and investigations for legal or compliance purposes.
• Work closely with claims assessors, investigators and legal team when required.
• Communicate findings, collaborate with other departments and elevate potential fraud cases and trends to key stakeholders and management.
• Provide training to claims staff on fraud detection techniques and red flags.
• Prepare detailed reports on investigations, findings, and recommendations.
• Ensure that investigations comply with industry regulations, company policies, and legal standards.
• Keep up to date with fraud-related legislation and best practices.
• Maintain organized and up-to-date case files, ensuring compliance with regulatory requirements.
• Propose and implement measures to reduce fraud risk, including process improvements and enhanced fraud detection methods.
• Assist in the development of fraud prevention programs and initiatives for the company.

Major Challenges

• Data accuracy and integrity
• Scope of potential fraud cases to identify and monitor
• Manual Discovery Processes
  -System Limitations
• Complex data sets

Major Job Accountabilities

• Analytics support
• Trend Analysis
• Continuous Improvement
• Educate employees

Success Measures

• Accuracy of Analysis
  - Reliability of the data analysis and conclusions.
• Stakeholder Satisfaction
  - Positive feedback from partners on the quality and usefulness of analyses and recommendations.
• Impact of Recommendations
  - The effectiveness of implemented recommendations in improving processes affecting outcomes.
• Continuous Improvement.

What skills and experience are we looking for?

• Bachelor’s degree or equivalent relevant experience
• A minimum of 5-7 years experience in medical claims handling, fraud investigation, insurance, or a related field.
• Strong investigative skills, critical thinking and attention to detail.
• Technical proficiency and a thorough understanding of data analysis software, fraud detection systems and cybersecurity measures.
• Familiarity with machine learning and artificial intelligence.
• Familiarity with financial regulatory compliance and insurance industry standards.
• Strong written and verbal communication skills.
• Excellent communication skills in English and French (French is considered an asset)
  English will be used in particular to carry out daily follow-ups with other departments in our various offices, whether in Ontario, or elsewhere.
• Full proficiency in Microsoft Office Suite with advanced Excel and Database skills.
• Familiarity with claims management processes and insurance industry standards.
• Analytical skills to interpret complex data sets.
• Strong communication skills to present findings clearly to stakeholders.
• Problem-solving skills to identify and address issues in data and processes.
• Ability to work independently and as part of a team.
• Ability to manage multiple tasks and prioritize…