Job Description:

The Senior Consultant, Claims Investigation Services (CIS) is responsible for department quality control and audit responsibilities in addition to leading complex investigations involving suspected fraud, abuse, misrepresentation, provider misconduct, and other irregular claim activity across Sun Life U.S. Supplemental Health products, including Accident, Critical Illness, Cancer and Hospital Indemnity.

Preferred skills

• Serve as the subject matter expert for Supplemental Health fraud investigations.
• Train claims professionals to identify fraud indicators and escalation triggers.
• Provide consultation and guidance on suspicious claims.
• Develop investigation playbooks, reference materials, and best practices.
• Foster awareness of fraud risks across Claims Operations.

Qualifications

• Bachelor's degree or equivalent experience.
• Strong analytical and problem-solving skills.
• Experience reviewing medical records and claim documentation.
• Ability to conduct complex investigations independently.
• Strong written and verbal communication skills.
• Experience presenting findings to senior leadership.

Responsibilities

Claims Investigations

• Lead investigations involving suspected fraud, abuse, provider misconduct, material misrepresentation, or organized fraud schemes.
• Conduct comprehensive reviews of claim files, supporting documentation, medical records, provider information, and payment history.
• Analyze claim activity to identify unusual patterns, trends, or indicators of fraud.
• Develop and execute investigation plans based on risk, complexity, and financial exposure.
• Determine appropriate investigative actions and escalation paths.
• Document investigative findings, recommendations, and outcomes.

Quality Audit & Claims Procedure Oversight

• Conduct quality audits of staff-processed claims to ensure consistent and accurate application of claim department guidelines, procedures, policy provisions, and benefit adjudication standards.
• Identify quality trends, error patterns, process gaps, and coaching opportunities that may impact claim accuracy, timeliness, member experience, or operational consistency.
• Provide audit findings, feedback, and recommendations to Claims Operations leaders to support staff development, procedural alignment, and continuous improvement.
• Maintain audit documentation and reporting to support quality control oversight, management review, and adherence to internal claim handling requirements.

Fraud Detection & Analytics

• Partner with Claims Analytics and Data Science teams to develop fraud detection methodologies.
• Identify high-risk claims through:
  • Claims frequency analysis
  • Repeat provider patterns
  • Repeat member behavior
  • Injury and diagnosis trends
  • Geographic anomalies
  • Payment concentration analysis
• Prioritize investigation inventory using risk-scoring methodologies.
• Quantify financial exposure and recoverable amounts.
• Identify emerging fraud schemes and recommend mitigation strategies.

Medical Record & Evidence Review

• Coordinate medical record procurement and evidence gathering activities.
• Validate submitted documentation against provider records.
• Evaluate claim eligibility, diagnosis validity, treatment patterns, and supporting evidence.
• Identify inconsistencies between claim submissions and medical records.
• Work with internal clinical resources as necessary to assess medical appropriateness and validity.

Regulatory, Legal & Compliance Support

• Partner with Legal, Compliance, Risk Management, and SIU to ensure investigations comply with applicable laws and regulations.
• Prepare investigation summaries and supporting materials for internal and external reviews.
• Support regulatory inquiries, audits, legal proceedings, and fraud reporting requirements.
• Maintain investigation documentation consistent with company protocols and legal requirements.

Fraud Prevention & Program Development

• Develop proactive fraud prevention strategies for Supplemental Health.
• Identify process vulnerabilities that may enable fraudulent activity.
• Recommend policy, workflow, automation, and control enhancements.
• Partner with Product, Operations, and Technology leaders on fraud mitigation initiatives.
• Support enhancement of fraud monitoring tools and investigative capabilities.

Training & Expertise

• Serve as the subject matter expert for Supplemental Health fraud investigations.
• Train claims professionals to identify fraud indicators and escalation triggers.
• Provide consultation and guidance on suspicious claims.
• Develop investigation playbooks, reference materials, and best practices.
• Foster awareness of fraud risks across Claims Operations.

Salary Range: $72,500 - $108,800

At our company, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions.

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