Job Description

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 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 continued success of the Group Benefits Operations. A key focus of the Investigation Consultant, Provider Risk is in the prevention, detection, and investigation of fraud and abuse specific to health care providers. 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 questions need and supports our claims experience management and the success of our overall Fraud Prevention Program. The individual in this role will draw on their analytical skills, investigative expertise, customer focus, Group Benefits background, understanding of the Canadian Healthcare environment, regulation, and legislation to figure out ongoing priorities in the delivery of provider controls. The incumbent 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 provider types and influence the decisions of new provider roles accepted through our electronic submission channel so that the integrity of our claims payment process is maintained. In this role the 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 incumbent must be highly skilled in decision making and negotiating as this position is regularly confronted with potentially contentious situations requiring immediate and appropriate responses. This role must be a confident communicator with an investigative background, have a technical proficiency with experience using analytical tools, demonstrate leadership skills to mentor 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 provider submit risk priorities, redesign the overall audit plan, and complete on-site provider audits 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, treatment plans, 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 needing immediate decisions and/or resolution
• Own 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 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 critical plan sponsor meetings with senior client personnel from legal, benefits, corporate investigations and their audit risk committees owning 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 leadership as needed through program feedback, 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 provider 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, Provider Risk role is the investigation of service providers, coaching of junior staff through various questions, support needs and investigation guidance, representation of the overall program to management, and to provide support for reporting and critical metrics on an ongoing basis. What motivates you?

• You obsess about customers, listen, engage and act for their benefit.
• You think big, with curiosity to discover ways to use your agile approach and enable business outcomes.
• You thrive in teams and enjoy getting things done together.
• You take ownership and build solutions, focusing on what matters.
• You do what is right, work with integrity and speak up.
• You share your humanity, helping us build an inclusive work environment for everyone.
  

What we are looking for

• Proven understanding of Group Benefits
• Certified Fraud Examiner (CFE) designation is an asset
• Knowledge of the Canadian healthcare environment, service delivery model and regulation
• University degree or equivalent work experience
• Solid understanding of fraud, abuse risk, and techniques to handle risk
• Strong research, problem solving and decision-making skills
• Own contentious interactions with various partners
• Excellent oral communication (both phone and face to face) and written communication skills
• Bilingualism is preferred, but not required
• Sophisticated data analysis skills with expertise using Excel and other data mining software
• Skills and ability to analyze and organize data to support analysis and recommendations
• Proven investigation skills with attention to detail
• Sophisticated interviewing skills
• Ability to coach and mentor 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 important.
  

What can we offer you?

• A competitive salary and benefits packages.
• A growth trajectory that extends upward and outward, encouraging you to follow your passions and learn new skills.
• A focus on growing your career path with us.
• Flexible work policies and strong work-life balance.
• Professional development and leadership opportunities.
  

Our commitment to you

• 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.

Every career at Manulife/John Hancock provides the opportunity to learn new skills and move your career forward. Ready to make an impact somewhere? What are you waiting for? Apply today. About John Hancock and Manulife John Hancock is a unit of Manulife Financial Corporation, a leading international financial services group that helps people make their decisions easier and lives better. We operate primarily as John Hancock in the United States, and Manulife globally, including Canada, Asia and Europe. We provide financial advice, insurance and wealth and asset management solutions for individuals, groups and institutions. Assets under management and administration by Manulife and its subsidiaries were CAD$1.3 trillion (US$1.1 trillion) as of June 30, 2021. Manulife Financial Corporation trades as MFC on the TSX, NYSE, and PSE, and under 945 on the SEHK. Manulife can be found at manulife.com . One of the largest life insurers in the United States, John Hancock supports more than 10 million Americans with a broad range of financial products, including life insurance , annuities , investments , 401(k) plans , and education savings plans . Additional information about John Hancock may be found at johnhancock.com . 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.