Claims Management Manager (Hybrid)

WHO WE ARE When it comes to health, we’re always looking for ways to push for better. It’s why we were founded in the first place. In 1957, our founder, pharmacist William Wilkinson, witnessed a mother sacrifice her health by foregoing her own medicine to pay for her sick daughter’s prescription. He knew there had to be a better way. So, he introduced North America’s first prepaid drug plan, and GreenShield was born as a not-for-profit with a mission to support better health for all Canadians. We aren’t just a health and benefits company. We’re the only not-for-profit social enterprise that brings worlds of coverage and care together, all in one place. We’re noble challengers, purposefully building a better way and we need the best people to help us create a more holistic approach that takes care of the mind and body. Our mission is to create better health for all Canadians, and we know that starts with our employees. 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.