Director, Claims Audit & Investigation Services

Alberta Blue Cross® is an Alberta based organization dedicated to delivering exceptional customer experience and community leadership. We’re committed to providing the best health coverage to over 1.8 million members and take an active role in promoting wellness. We believe in what we do - and place trust in our employees to deliver our vision.

Working at Alberta Blue Cross® means having a career where you’ll be recognized for your contributions. We value diversity, encourage our team members to maintain a healthy work-life balance and provide opportunities for career growth.

OVERVIEW:

Reporting to the Senior Vice President & Chief Financial Officer, the Director, Investigation Services and Claims Audit leads the Investigation Services and Claims Audit function. This role is accountable for protecting the integrity and sustainability of our benefit plans and programs through effective claims audit, investigation, prevention and education activities. The Director provides strategic leadership, develops strong partnerships across the organization and uses data, analytics and technology to identify risk, improve controls and support sound business decisions. This is an integral role in the organization.

WHAT YOU WILL DO:

• Lead, coach and develop an engaged, high-performing Investigation Services and Claims Audit team. 
• Develop and execute a multi-year strategy for claims audit, investigations, fraud risk management, prevention and education that aligns with organizational priorities. 
• Oversee risk-based claims audit and investigation programs focused on member, provider and plan compliance. 
• Build strong, collaborative relationships across the organization and with external stakeholders, including providers, plan sponsors, regulators and law enforcement, as appropriate. 
• Develop a deep understanding of benefit programs, claims processes and controls, and recommend actions to reduce risk and strengthen program integrity. 
• Advance the use of data analytics, artificial intelligence and other technology to identify emerging risks, improve case selection and enhance investigative effectiveness. 
• Establish meaningful performance measures and provide clear, timely reporting and advice to the Senior Vice President & Chief Financial Officer, senior leadership and relevant Board committees. 
• Continuously improve claims audit and investigation methods, operating practices and service delivery. 
• Provide thoughtful leadership in sensitive and complex matters, balancing fairness, customer experience, confidentiality and comprehensive reporting. 
• Champion prevention, awareness and education to strengthen compliance.

WHAT YOU WILL HAVE:

• Relevant professional designation or post-secondary education in accounting, finance, business, law, investigations or a related field. A CPA, CIA, CFE or comparable accreditation is preferred. 
• Progressive leadership experience in claims audit, investigations, fraud risk management, compliance, internal audit or a related discipline. 
• Experience leading complex investigations and audit programs in a regulated, insurance, health benefits or financial services environment is an asset. 
• Strong knowledge of investigation practices, evidence handling, procedural fairness, privacy and confidential information management. 
• Exceptional interpersonal, verbal and written communication skills, with the ability to present complex matters clearly to senior leaders and Board committees. 
• Demonstrated ability to identify opportunities, develop effective strategies and deliver measurable results. 
• Proven success managing diverse, complex initiatives within established timelines and expectations. 
• Strong analytical judgment, problem-solving skills and experience using data to identify patterns, trends and risk. 
• A record of developing talent through coaching, mentoring and thoughtful performance leadership. 
• Demonstrated ability to build trusted relationships and collaborate across organizational boundaries. 

This position will remain open until a suitable candidate is selected.

Alberta Blue Cross® is an inclusive employer committed to a workplace that reflects the diversity of the communities we serve. We empower and are advocates for our team members by welcoming, respecting and valuing their unique perspectives, backgrounds, and experiences.

We offer the opportunity to work in an innovative, high-energy team-focused environment. If you have the qualifications we are looking for, apply online at careers.ab.bluecross.ca

A criminal record check satisfactory to Alberta Blue Cross will be required as a condition of employment, following a conditional offer.