THE ROLE IN A NUTSHELLBase Salary: CAD $94,406.00 - 142,069.00
THE ROLE IN A NUTSHELL We are seeking a strategic and analytical Claims Management Manager, responsible for building and executing a comprehensive claims oversight framework that enhances financial integrity, operational efficiency, and member experience. This individual contributor role will serve as a key enterprise resource, driving initiatives across auditing, anomaly detection, and adjudication optimization. The Manager will collaborate with finance, pricing, fraud, automation, and product teams to identify cost drivers, mitigate risks, and ensure claims processes align with organizational objectives and industry benchmarks.
Roles and Responsibilities 1. Claims Oversight and Auditing
- Evaluate existing plan designs for gaps or inefficiencies and recommend enhancements such as Health Spending Accounts (HSAs), maximums, and prior authorization criteria.
- Conduct regular audits of plan setup in administrative systems to ensure accurate adjudication logic.
- Partner with internal stakeholders to validate plan configurations and prevent operational errors.
2. Anomaly Detection and Trend Analysis
- Collaborate with Financial Planning & Analytics and pricing teams to develop dashboards and predictive models for identifying emerging cost drivers and utilization patterns.
- Build predictive models for high-cost claims, chronic disease prevalence, and utilization patterns.
- Develop scenario analysis for catastrophic claims and emerging health risks.
- Analyze Customer Relationship Management and Claims Data Management data to detect unusual claims activity and feed insights into fraud detection and plan design workflows.
- Assess provider-level analytics to uncover patterns contributing to overbilling or inflated costs.
3. Strategic Reporting & Insights
• Develop dashboards for claims trend by claim type and provide actionable intelligence to leadership.
• Deliver quality insights on cost drivers and emerging risks.
• Support executive decision-making with scenario modeling.
4. Root Cause Analysis and Rule Optimization
- Perform deep-dive investigations into transactional data to identify adjudication rule gaps.
- Work with automation and plan build teams to refine rules and improve processing accuracy.
- Recommend system enhancements to reduce manual interventions and improve adjudication speed.
5. Billing and Financial Alignment
- Partner with AR/Billing teams to reconcile member counts, commission structures, and recoveries.
- Validate that billing accurately reflects plan utilization and enrollment setup.
- Ensure commission recovery processes align with claims adjustments.
6. Fraud, Waste, and Abuse Collaboration
- Work closely with fraud teams to analyze recovered cases and integrate insights into claims workflows.
- Explore partnerships with external fraud analytics vendors to strengthen detection capabilities.
WHO WE'RE LOOKING FORWe're not looking for just anyone. We're looking for a unique individual with a big brain and a big heart who wants to help us create better health for all Canadians.
- Bachelor's degree in Finance, Mathematics, Data Analytics, or a related field. Master's degree would be an asset.
- ASA Required. FSA Preferred.
- 5+ years of experience in claims management, health benefits, or insurance operations.
- Strong analytical and investigative skills with the ability to interpret complex data and identify actionable insights.
- Proficiency in data analysis tools and platforms (SQL, R, Tableau, Power BI).
- Experience with auditing, anomaly detection, and process optimization.
- Ability to collaborate across multiple teams and influence enterprise-level decisions.
- Excellent attention to detail and accuracy, with a focus on meeting deadlines.
THE CULTUREWe believe a career should be meaningful. Not just a means to earn a living. Our culture is one where everyone's voice is heard and valued. Because that's what it takes to create better health for all. We dare to challenge the status quo. And we're driven by people who have challenged theirs. We believe that your workplace should empower you to be the best version of yourself. That's why we provide a place where you can be inspired, challenged, and rewarded.
Where your growth means our growth.
Where your voice is heard and valued.
Where your work has purpose. And purpose matters.
We believe our people are critical to our overall success. Inclusivity makes us a stronger, smarter and more informed organization. Being intentionally inclusive of diverse backgrounds, perspectives and experiences will enhance our company culture to positively impact how we support our communities. A career at GreenShield isn't just about personal achievements, it's about making a difference together.
Here's to Better Health for All!
AFEW MORE DETAILSProficiency in English is required for this position. As part of this role, you will be required to communicate with colleagues or customers who use English as their primary language. By requiring English proficiency for this position, we aim to ensure that our employees can excel in their roles, collaborate, and communicate effectively, and contribute to the success of our organization.
GS supports diversity, equity and inclusion in our teams and communities, and we value the unique contributions made by all. Even if your experience doesn't align perfectly to every requirement, we invite you to apply.
