Pharmacy Profiling Investigator

You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

Job Description:

Fraud management is increasingly important to policyholders. In order to serve Sun Life’s clients as industry leaders, Canadian Operations’ Fraud Risk Management area will identify, mitigate and respond to criminal threats using various tools, technologies and strategies. With $2.5 billion paid in drug claims annually, the Investigator investigates pharmacy fraud and abuse detection by using predictive models, pattern analysis, profiling and other intelligence-led strategies. The Pharmacy Profiling Investigator will address the requirements needed to sustain the program and coordinate the leads for investigation on an on-going basis. With the need to continuously adapt and evolve to keep ahead of fraud trends and emerging schemes, the Investigator will also liaise with Sun Life’s drug benefits administrator in the management of pharmacy audits and controls.

Reporting to the Manager, Fraud Risk Management (FRM), the Pharmacy Profiling Investigator will work in partnership with other FRM specialists, leaders and areas that support the team and service delivery such as Member Drug Investigators and Analysts, Business Analytics, Pharmacy Consultant, Legal, Compliance, Business Development, Customer Care Centre, and Group Benefits Health & Dental Claims.

What will you do?

• Collaborate with Business Analytics and other key partners in identifying the principles and dataset for predictive models and pattern analysis

• Develop an action plan to track leads, identify investigative steps, pursue recoveries and deliver results related to pharmacy profiling

• Act as a subject matter expert for drug related anti-fraud and abuse claim submissions and pharmacy schemes

• Conduct regular assessments on the quality of leads, prioritization of investigations and decisions made on cases

• Remain up to date on new drugs, products and privacy laws

*** Must be able to obtain Reliability Status through the Government of Canada (includes a background check with fingerprinting by the RCMP). ***

What do you need to succeed?

• As this position is posted in several locations, we specify that bilingualism (French, English, both oral and written) is required for Quebec only for the frequent interactions with English and French-speaking colleagues or internal partners across Canada or worldwide.

• Pharmacy Technician - Minimum of 3 years full time retail or hospital experience

• In depth understanding of various drugs and categories, pharmacy drug submission process and audit opportunities, both prepayment and post payment

• Proven ability to influence solutions and facilitate cross-departmental teamwork that meets the needs of the business strategy

• Excellent collaboration and team building skills

• Strong analytical skills and critical thinking with attention to accuracy and details

• Solid decision making skills by understanding and assessing business needs and risks

• Superior organizational skills and ability to prioritize initiatives and execute effectively

• Advanced computer skills (Word, Excel, Lotus Notes, PowerPoint)

Assets:

• Previous exposure to group insurance business (products, services, distribution, organization, systems, processes) and its regulatory environment across provinces

• Previous experience auditing the billing practices of pharmacies

• Strong knowledge of drug claims submission and processing

• Knowledge of Tableau or other data visualization tools

• Registered Pharmacy Technician

• CFE designation

Location & travel:

• This position will be in Waterloo or Montreal

• Some travel to other Sun Life offices, and for education seminars or conferences

#LI-Hybrid

The Base Pay range is for the primary location for which the job is posted. It may vary depending on the work location of the successful candidate or other factors. In addition to Base Pay, eligible Sun Life employees participate in various incentive plans, payment under which is discretionary and subject to individual and company performance. Certain sales focused roles have sales incentive plans based on individual or group sales results.

Diversity and inclusion have always been at the core of our values at Sun Life. A diverse workforce with wide perspectives and creative ideas benefits our clients, the communities where we operate and all of us as colleagues. We welcome applications from qualified individuals from all backgrounds.

Persons with disabilities who need accommodation in the application process or those needing job postings in an alternative format may e-mail a request to thebrightside@sunlife.com.

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

We thank all applicants for showing an interest in this position. Only those selected for an interview will be contacted.

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