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Senior Consultant – Claims Investigation Services
Sun Life. Lead complex investigations involving suspected fraud, abuse, provider misconduct, material misrepresentation, organized fraud schemes, and other irregular claim activity across Supplemental Health products .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in leading complex investigations into fraud and abuse within Supplemental Health products, utilizing strong analytical skills to identify patterns and trends. Proficient in developing investigation plans, conducting quality audits, and collaborating with cross-functional teams to enhance fraud detection and prevention strategies.
Highest-signal resume keywords
Fraud InvestigationAnalytical SkillsMedical Record ReviewCommunication SkillsProblem-Solving
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Fraud Detection MethodologiesInvestigation PlanningQuality AuditingData AnalysisDocumentation Review
Soft Skills
Strong CommunicationIndependent WorkCoaching
Certifications & Qualifications
Bachelor's Degree
Industry Keywords
Claims OperationsFraud PreventionRisk ManagementComplianceProvider Misconduct
About the role
Key responsibilities & impact- Lead complex investigations involving suspected fraud, abuse, provider misconduct, material misrepresentation, organized fraud schemes, and other irregular claim activity across Supplemental Health products
- Conduct comprehensive reviews of claim files, supporting documentation, medical records, provider information, and payment history
- Analyze claim activity to identify unusual patterns, trends, and fraud indicators
- Develop and execute investigation plans based on risk, complexity, and financial exposure
- Determine investigative actions and escalation paths
- Document investigative findings, recommendations, and outcomes
- Conduct quality audits of staff-processed claims for accurate application of guidelines, procedures, policy provisions, and adjudication standards
- Identify quality trends, error patterns, process gaps, and coaching opportunities
- Provide audit findings, feedback, and recommendations to Claims Operations leaders
- Maintain audit documentation and reporting
- Partner with Claims Analytics and Data Science teams to develop fraud detection methodologies
- Prioritize investigation inventory using risk-scoring methodologies
- Quantify financial exposure and recoverable amounts
- Identify emerging fraud schemes and recommend mitigation strategies
- Coordinate medical record procurement and evidence gathering
- Validate documentation against provider records
- Evaluate claim eligibility, diagnosis validity, treatment patterns, and supporting evidence
- Partner with Legal, Compliance, Risk Management, and SIU on compliant investigations
- Prepare investigation summaries and materials for reviews, inquiries, audits, legal proceedings, and fraud reporting
- Develop proactive fraud prevention strategies and recommend policy, workflow, automation, and control enhancements
- Partner with Product, Operations, and Technology leaders on fraud mitigation initiatives
- Train claims professionals to identify fraud indicators and escalation triggers
- Develop investigation playbooks, reference materials, and best practices
- Foster fraud-risk awareness across Claims Operations
Requirements
What you’ll need- Bachelor's degree or equivalent experience
- Strong analytical and problem-solving skills
- Experience reviewing medical records and claim documentation
- Ability to conduct complex investigations independently
- Strong written and verbal communication skills
- Experience presenting findings to senior leadership
Benefits
Comp & perks- Discretionary annual incentive award based on individual performance and overall business performance
- Generous vacation and sick time
- Paid family, parental and adoption leave
- Medical coverage
- Company-paid life and AD&D insurance
- Disability programs
- Partially paid sabbatical program
- 401(k) employer match
- Stock purchase options
- Employer-funded retirement account
- Flexible, inclusive and collaborative work environment
- Career growth support