Job Description

Description :
Saskatchewan Blue Crossxc2xae, one of Saskatchewans Top Employers, is currently recruiting for a full-time permanent Claims Integrity Specialist to join our team in the Health & Dental Claims department. This position offers the flexibility to be in-office or participate in hybrid options in our Saskatoon or Regina office.
JOB FUNCTION
The Claims Integrity Specialist is responsible for the execution of key operational audit and assurance activities that support the overall quality, consistency, and integrity of claims practices and payments. This role will apply audit and analytical tools and techniques to verify the reasonableness of incurred expenses, the legitimacy of expenses claimed, the accuracy of amounts paid, and support the detection and investigation of anomalous or outlier claims.
WHY CHOOSE SASKATCHEWAN BLUE CROSS?
Were driven by a mission to empower communities on their journey to whole health and wellness, and have a lot of exciting things ahead of us. Were improving our members experiences through investment in our people, technology, services and products. When you join our team, youre joining an organization where employees are valued, recognized for their contributions and empowered to make us stronger. The wellbeing of our employees, our members, our partners and our communities is at the heart of our operations.
Our industry is evolving fast, and so are we! Were looking for people who:

• Share our values
• Believe that creating great experiences is totally within their control
• Collaborate and always set others up for success
• Build positive relationships and an understanding of what peoples needs are
• See solutions and possibilities (not problems!)
• Are simply outstanding at what they do

• Execute strong provider credentialing practices, which may include corresponding with professional associations and regulatory bodies, as well as maintain and update approved provider files
• Action provider requests for electronic billing
• Complete regular provider updates
• Evaluate, request, and audit the set-up, revision, or removal of system maps and rules for the accurate calculation of benefits
• Remain current with product and procedural knowledge
• Provide cross-functional and general administrative support
• Conduct routine quality and integrity assurance audits on processed claims, including member and provider submissions
• Conduct routine to complex investigations on uncovered, reported, and/or suspected claims fraud, abuse, or waste
• Correspond with members and/or providers to obtain information in relation to a claims audit
• Liaise with professional associations, regulatory bodies, law enforcement officials, and others to obtain assistance in conducting investigations and/or pursuing disciplinary actions or remediations
• Suggest opportunities for improvements in operational workflows and processes

• Bachelors Degree in a related field from a recognized institution, or an equivalent combination of experience and education
• Previous experience working in the insurance industry, experience in fraud investigation, or a Certified Fraud Examiner designation would be considered an asset
• Demonstrated knowledge of current and emerging fraud schemes and investigation best practices
• Well organized, detailed oriented and a desire for investigative and research activities
• Analytical, problem-solving and decision-making capabilities
• Demonstrated ability to work to deadlines and manage fluctuations in workload
• Working knowledge of Microsoft Word and Excel with a demonstrated ability to easily learn new software programs
• Effective listening, interpersonal and problem-solving skills
• Excellent verbal and written communication skills
• Ability to work independently, as well as in a group environment
• Legally entitled to work in Canada on an unrestricted basis
• Criminal Record and background check satisfactory to Saskatchewan Blue Cross