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About the Role

We are seeking a strategic and analytical Claims Management Manager responsible for building and executing a comprehensive claims oversight framework to enhance 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.

Responsibilities

• 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.
• 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.
• 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.
• 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.
• 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.
• 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.

Requirements

• Bachelor’s degree in Finance, Mathematics, Data Analytics, or a related field.
• ASA Required. FSA Preferred.
• 5+ years of experience in claims management, health benefits, or insurance operations.
• Strong analytical and investigative skills with the ability to interpret complex data and identify actionable insights.
• Proficiency in data analysis tools and platforms (SQL, R, Tableau, Power BI).
• Experience with auditing, anomaly detection, and process optimization.
• Ability to collaborate across multiple teams and influence enterprise-level decisions.
• Excellent attention to detail and accuracy, with a focus on meeting deadlines.
• Proficiency in English is required.

Skills

• Data Analysis
• Auditing
• Anomaly Detection
• Process Optimization
• SQL
• R
• Tableau
• Power BI
• Scenario Modeling
• Fraud Detection

Location

• Canada

Work Type

• Full-time

Experience Level

• 5+ years

Education Level

• Bachelor's degree
• Master's degree (preferred)
• ASA
• FSA (preferred)

Salary/Compensations

• CAD $94,406.00 - 142,069.00

About the Company

• GreenShield is a proudly Canadian, national non-profit health care and insurance organization, driven by our mission of Better Health for All.
• We believe health care is a right, not a privilege, and we are committed to improving health outcomes, advancing health equity, and building a future where every Canadian can reach their full health and well-being potential.
• Through our unique integrated payer-provider ("payvider") model, we offer insurance, administer benefits, and pay claims as a ‘payer’ while offering health care services such as mental health, pharmacy, telemedicine, and chronic disease management as a ‘provider’.
• As a non-profit social enterprise without shareholders, we reinvest our excess earnings to directly support underserved communities.
• Through GreenShield Cares, we positively impacted the health and well-being of over one million Canadians between 2020 and 2025.
• Our mission is to measurably impact an additional three million Canadians by 2030 – across mental health, essential medicines, and chronic disease management – through scalable initiatives that deliver meaningful change in pursuit of our mission of Better Health for All.
• At GreenShield, our culture is where purpose meets passion and performance.
• Our teams work as one to deliver meaningful, measurable impact for the people and communities we serve.
• 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.
• We believe a career should be meaningful. Not just a means to earn a living.
• Our culture is one where everyone's voice is heard and valued.
• We dare to challenge the status quo. And we’re driven by people who have challenged theirs.
• We believe that your workplace should empower you to be the best version of yourself.
• We believe our people are critical to our overall success.
• Inclusivity makes us a stronger, smarter and more informed organization.
• Being intentionally inclusive of diverse backgrounds, perspectives and experiences will enhance our company culture to positively impact how we support our communities.
• A career at GreenShield isn’t just about personal achievements, it's about making a difference together.

Equal Opportunity

• GS supports diversity, equity and inclusion in our teams and communities, and we value the unique contributions made by all.
• Even if your experience doesn’t align perfectly to every requirement, we invite you to apply.
• We encourage applications from all candidates and will accommodate needs under human rights legislation throughout all stages of the recruitment and selection process.
• Please let us know of any accommodation through requestforaccommodation@greenshield.ca.
• Information received relating to accommodation will be addressed confidentially.