Claims Integrity Specialist

  • Location:
  • Department:
    Health and Dental Claims
  • Posting ID:
  • Position type:
    Full Time


Reporting directly to the Manager, Health & Dental Claims, this position 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. As a member of the team, the successful incumbent will apply audit and analytical tools and techniques to verify the reasonableness of incurred expenses, the legitimacy of expenses claimed, and the accuracy of amounts paid, and support the detection and investigation of anomalous or outlier claims.



  • Develop and execute strong provider credentialing practices, as well as maintain and update approved provider files
  • Evaluate, request, and audit the set-up, revision, or removal of system maps and rules for the accurate calculation of benefits
  • 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 that includes:
    • detailed analysis and interpretation of data to prioritize investigative efforts and identify trends
    • detailed collection of supporting evidentiary materials or information to substantiate hypotheses and conclusions
    • preparation of comprehensive reports that include evidence findings, results, and recommended recovery actions
    • assist with recommendations for possible civil or criminal action with law enforcement agencies where warranted
    • assist with the preparation of required court documentation and serve as an expert witness for litigation proceedings where warranted
  • Correspond with members and/or healthcare professionals on a regular basis
  • Liaise with professional associations and 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
  • Remain current with product and procedural knowledge
  • Provide cross-functional and general administrative support
  • Perform other duties as required



  • Bachelor’s Degree in a related field from a recognized institution and a minimum of 3 years experience in fraud investigation. Equivalent combination of experience and education will be considered
  • Preference will be given to candidates that hold a Certified Fraud Examiner designation
  • Previous experience working in the insurance industry 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
  • The successful candidate will be required to undergo a background check
  • Must be legally entitled to work in Canada on an unrestricted basis
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