Investigator – Claims Audit & Investigation Services

About the Role

Join an Alberta-based organization dedicated to advancing the health and wellness of over 1.8 million members. Alberta Blue Cross is committed to fostering a positive workplace that values diversity, work-life balance, and career development. As part of the Claims Audit & Investigation Services team, you will play a crucial role in detecting, investigating, and reporting potential fraud or non-compliance related to dental and health benefits claims, ensuring adherence to provider agreements, policies, and applicable laws.

Key Responsibilities

• Conduct thorough health and dental audits and investigations, ensuring all reporting adheres to regulatory and internal standards.
• Perform on-site documentation collection, requiring travel throughout Alberta (must hold a valid Class 5 Driver's License).
• Analyze claims to verify compliance with provider agreements, contracts, organizational policies, and statutory requirements.
• Organize and maintain audit workpapers, and prepare correspondence and formal reports.
• Issue findings regarding claims, suggesting financial adjustments or recommending changes in provider practices for compliance purposes.
• Foster collaborative relationships with service providers and internal teams.
• Efficiently address escalated client issues and prioritize workload to maintain high service standards.
• Suggest improvements for processes, policies, and procedures to enhance productivity and service delivery.

Required Qualifications & Skills

• Post-secondary education in any of the following: science or business, criminal justice, health care, or law. Equivalent law enforcement experience may be considered in lieu of formal education.
• Preferred investigative certification (such as CFI or CFE), or significant relevant experience as a substitute for credentialing.
• 3–5+ years of investigation experience.
• Strong written and verbal communication skills, including experience in investigative interviewing.
• Dedicated to exceptional customer service, with a proven ability to build effective working relationships with diverse stakeholders.
• Proficient in analyzing large datasets, particularly using Microsoft Excel and related databases.
• Capable of working independently within a virtual and team-oriented environment, demonstrating accountability and responsibility.
• Previous experience within health care benefits or a related health field is considered an asset.

Additional Information

• The position remains open until a suitable candidate is found.
• A satisfactory criminal record check is required as a condition of employment and will be conducted after a conditional offer is extended.
• Alberta Blue Cross is devoted to inclusion, welcoming applicants from diverse backgrounds and promoting equity within the workplace.

Work Environment & Perks

• Innovative and dynamic team environment.
• Career development opportunities in a forward-thinking organization.
• Emphasis on work-life balance and employee recognition.