Claims Fraud Investigator

At Pacific Blue Cross, we're committed to improving health and wellbeing for British Columbians. As our Claims Fraud Investigator, you will play a vital role in protecting our members, providers, and benefit programs by identifying, investigating, and addressing suspected fraud, abuse, and non-compliant activity related to dental and extended health claims.

Reporting to the Director, Claims Fraud & Abuse Investigations, you will leverage your investigative expertise, critical thinking, analytical skills, and attention to detail to identify suspicious claim activity, conduct comprehensive investigations, and pursue the recovery of ineligible funds. This role combines data analysis, evidence-based decision making, and problem solving, requiring someone who thrives in complex situations, can navigate ambiguity, and is comfortable working with large volumes of information.

We're seeking a highly motivated, self-driven professional who brings strong investigative capabilities, sound judgement, and a customer-centric approach. You'll collaborate with internal stakeholders, healthcare practitioners, providers, legal professionals, compliance teams, regulatory bodies, and law enforcement agencies to assess risk, gather evidence, and help protect the integrity of Pacific Blue Cross's health and benefits programs.

The ideal candidate brings experience conducting investigations, audits, compliance reviews, fraud detection activities, or analyzing healthcare, insurance, financial, regulatory, or other complex data sets to identify trends, anomalies, risks, and potential instances of non-compliance or fraud.

If you have experience understanding healthcare benefits, claims, billing practices, regulatory compliance, investigations, or health services in roles such Claims Investigator, Fraud Investigator, Healthcare Compliance Specialist, Regulatory Compliance Analyst, Claims Auditor, Insurance Investigator,Special investigations, Special Unit Investigator, we'd love to hear from you.

Key Details

• Position Title: Claims Fraud Investigator
• Work Arrangement: Hybrid - 3 days in the office and 2 days’ work from home
• Office Location: 4250 Canada Way, Burnaby, BC V5G 4W6
• Classification: Exempt
• Salary Range: $ 62,000 - $92,000 (Pacific Blue Cross’ compensation program is built on a pay-for-performance philosophy, rewarding both individual and organizational achievements. We determine starting salaries by considering a variety of factors, including relevant skills, education, experience, and internal equity, ensuring compensation decisions are consistent, equitable, and reflective of each candidate’s unique background and qualifications
• Incentive Compensation Plan (ICP bonus) per year based on performance: Up to 8.00%

Total Rewards Highlights:

• Flexible working hours of 7.5 hours per day, Monday to Friday (i.e., 37.5 hours per week).
• Paid vacation starts at 4 weeks per year and increases with years of service.
• Generous benefits, including extended health, dental, and life insurance; depending on the plan that you choose, these benefit premiums can be 100% paid by PBC.
• PBC contributes the equivalent of 8% of your base salary to a Defined Contribution pension plan. No employee contribution or matching is required, giving you more take-home pay

About Pacific Blue Cross

Pacific Blue Cross (PBC) has been British Columbia’s leading benefits provider for over 80 years. We are an independent, not-for-profit society with strong roots in BC’s health care system.

Why You'll Love Working Here

• Retiree Benefits plan that is available to employees who have at least 10 years of service with PBC and have reached the age of 55.
• Access to an onsite fitness center and cafeteria, along with employee events and activities designed to foster a collaborative and engaging work environment.
• Access to virtual doctors/counsellors 24/7 via our Employee Family Assistance Program!
• Learning and development opportunities
• Wellness initiatives and onsite amenities

Keyways This Position Makes an Impact

Success in this role means protecting the integrity of Pacific Blue Cross's health benefits programs while ensuring members and providers are treated fairly and responsibly. As a Claims Fraud Investigator, you will play a critical role in identifying fraudulent activity, mitigating organizational risk, and supporting the recovery of ineligible funds, helping ensure benefit dollars are used as intended for the wellbeing of British Columbians.

In this position, you will:

• Lead complex fraud and abuse investigations involving dental and extended health claims, evaluating evidence, identifying suspicious activity, conducting interviews with members, providers, and other relevant parties, and determining appropriate investigative and recovery actions
• Drive data-informed investigations by analyzing large volumes of claims, provider, utilization, billing, and healthcare data to identify patterns, trends, anomalies, and emerging fraud risks.
• Ensure high-quality investigative outcomes through thorough evidence gathering, detailed documentation, chain of custody management, and the preparation of comprehensive investigative reports and recommendation
• Support fraud prevention, recovery, and compliance efforts by collaborating with healthcare practitioners, providers, legal professionals, regulatory bodies, and law enforcement agencies to protect the integrity of benefit programs.
• Apply critical thinking and sound judgement to complex cases, navigating ambiguity, assessing risk, and making evidence-based decisions that support organizational objectives and exceptional service to members and providers.

What You'll Bring

• Bachelor’s degree in Criminology, Business, or an equivalent discipline.
• Certified Fraud Examiner certification, or equivalent.
• 3 – 5 years of related experience in fraud investigation or similar experience in reviewing, interpreting and analyzing extended health claims to identify potential areas of fraud or insurance abuse.
• Knowledge of current and emerging fraud and insurance abuse schemes and investigation practices.
• Advanced Excel (complex data manipulation, statistical analysis, filtering and advanced use of formulas, pivot tables, and functions).

Key Competencies

• Ability to work on multiple projects, to prioritize, and to meet deadlines
• Excellent observation and verbal/written communication skills, which includes report writing
• Ability to effectively plan, prioritize and follow through in a timely manner and with anticipation of potential roadblocks
• Strong analytical and logical thinking and sound judgement skills with the ability to solve complex problems

Preferred Qualifications

• Knowledge of the Health Professions Act.

Ready to Apply?

If you're excited about this opportunity and eager to make an impact, we'd love to hear from you. When applying please ensure to upload your cover letter and resume. We thank all applicants for their interest. Only candidates selected for an interview will be contacted.

Diversity, Equity & Inclusion

At Pacific Blue Cross, we are committed to creating a workplace where everyone feels valued, respected, and empowered to contribute. We welcome applications from all qualified candidates and are proud to be an equal opportunity employer.

We believe diversity, equity, and inclusion are essential to fostering innovation, collaboration, and a strong sense of belonging. Through ongoing learning, meaningful action, and community partnerships, we continue to build an inclusive culture where employees and members can thrive.

If you require accommodation at any stage of the recruitment process, please contact [email protected]. We are committed to providing accessible and inclusive candidate experience.