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Bilingual Dental Auditor-Express Scripts Canada
4 weeks ago
The role of the Fraud, Waste and Abuse team is to enhance the Express Scripts Canada (ESC) value proposition for customers to ensure the integrity of health claims while maintaining a network of providers through diligent review and education. The Dental Benefit Auditor is responsible to conduct various types of audits across Canada to validate that providers are compliant with benefit plan design and professional practice regulations. The Auditor uses their analytical and investigative skills along with their practice and knowledge of provincial benefit coverage to identify trends observed from claim reviews and to ensure that the audit techniques evolve to remain effective in managing risk for ESC customers.
Essential Functions:
Perform claim verifications, desk and/or on-site audits
Communicate with providers to gather information for audits, to educate on claim submission practices and to respond to queries in regards to audit results
Assess provider documentation to ensure compliance with enrolment agreement, benefit plan design and provincial regulations.
Calculate the adjustments required to correct claim transactions
Prepare, coordinate and travel to conduct on-site audit at the providerâs location, and complete the post on-site audit activities
Compile and produce audit reports that are detailed and unbiased
Perform self and peer-review to ensure accuracy and quality of claim reviews
Track audit activity and summarize results of claim analysis and recoveries on a daily and/or monthly basis for department statistics for presentation to customers
Identify trends observed from claim reviews and provide recommendations for risk criteria changes and/or candidates for a desk or on-site audit.
Recommend incremental and continuous ideas that will increase ability to prevent and manage risk that will bring the most value to customers
Respond to internal and external customer questions professionally, timely and accurately
Other duties and responsibilities as assigned
Qualifications:
2-5 years recent experience in a dental office environment with working knowledge of dental software and fee codes
Valid driverâs license and ability to travel in Canada, range of 20-30% of time
Graduate of post-secondary educational program either as a dental assistant or dental hygienist with a valid license
Bilingualism (French & English) is a must.
Experience in data analysis, financial and statistics.
Experience in report writing.
In-depth knowledge of dental benefits, reimbursement and dental regulations
Previous audit/investigation experience is an asset
Ability to manage confidential information
Effective time management and organizational skills
Strong critical thinking skills with ability to analyze, problem-solve and mediate difficult situations
Self-driven, curious, capable of working independently with minimal supervision
Strong interpersonal skills: team player and ability to work cross-functionally with other departments
Flexible, resourceful, with a mindset that embraces and champions change
Ability to manage high priority tasks in a fast paced environment
Ability to research and effectively communicate findings
Passionate about development and continuous learning
Excellent verbal and written communication skills
Proficiency in MS Office (Excel, Word, Outlook).
Life Office Management Association (LOMA) or Health Insurance Association of America (HIAA) training would be an asset
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Le rôle de lâéquipe de vérification en matière de fraude, de gaspillage et dâabus consiste à offrir des services à valeur ajoutée aux clients dâExpress Scripts Canada en veillant à lâintégrité des demandes de règlement pour soins de santé et en conservant un solide réseau de fournisseurs grâce à des examens diligents et à des conseils. Le vérificateur en soins dentaires est chargé dâeffectuer différents types de vérifications partout au Canada afin de vérifier si les fournisseurs respectent les dispositions des régimes et les règles de pratique professionnelle. Le vérificateur utilise ses compétences en matière dâanalyse et dâenquête ainsi que ses connaissances et son expérience en matière de couverture des soins de santé à lâéchelle provinciale afin de déceler des tendances dans les demandes de règlement. Il sâassure également que les techniques de vérification évoluent afin de demeurer efficaces dans la gestion des risques auxquels les clients dâExpress Scripts Canada sont exposés.
Responsabilités principales
Effectuer lâexamen des demandes de règlement ainsi que des vérifications à distance et sur place.
Communiquer avec les fournisseurs pour obtenir des renseignements relatifs aux vérifications, les informer sur la manière de soumettre leurs demandes de règlement et répondre à leurs questions sur les résultats des vérifications.
Sâassurer que les documents transmis par les fournisseurs respectent lâentente quâils ont conclue avec Express Scripts Canada, ainsi que les dispositions des régimes et les lois provinciales.
Calculer les rajustements qui sont requis pour corriger les demandes de règlement.
Coordonner les vérifications sur place, sây préparer et se déplacer pour les effectuer dans les établissements des fournisseurs, puis réaliser les différentes activités qui y sont associées.
Produire un rapport de vérification détaillé et impartial.
Réviser son propre travail ainsi que celui de ses collègues afin de sâassurer de lâexactitude des données et de la qualité de lâexamen des demandes de règlement.
Effectuer un suivi des activités de vérification et résumer les résultats de lâanalyse des demandes de règlement et des recouvrements sur une base quotidienne ou mensuelle afin dâétablir des statistiques pour le Service de vérification en matière de fraude, de gaspillage et dâabus qui seront présentées aux clients.
Cerner les tendances qui peuvent être observées par suite de lâexamen des demandes de règlement et fournir des recommandations sur les modifications des critères de risque ou sur les fournisseurs qui pourraient faire lâobjet dâune vérification à distance ou sur place.
Proposer des idées novatrices qui permettront dâaméliorer la capacité de prévenir les risques et de les gérer afin dâoffrir des services à valeur ajoutée aux clients.
Répondre rapidement aux questions des clients à lâexterne comme à lâinterne, avec professionnalisme et exactitude.
Effectuer toute autre tâche demandée.
Compétences recherchées
Posséder de 2 à 5 années dâexpérience récente en cabinets dentaires et connaître les logiciels utilisés par ces cabinets ainsi que les codes dâactes dentaires.
Posséder un permis de conduire valide et être en mesure de se déplacer au Canada entre 20 et 30 % du temps.
Ãtre titulaire dâun diplôme dâassistant dentaire ou dâhygiéniste dentaire et dâun permis dâexercice valide.
Ãtre bilingue (français et anglais) est essentiel.
Posséder de lâexpérience en analyse de données, notamment de données financières et statistiques.
Posséder de lâexpérience en rédaction de rapports.
Posséder des connaissances approfondies des règles en matière de régimes de soins dentaires, dâactes dentaires et de remboursement.
Posséder de lâexpérience en matière de vérification ou dâenquête constitue un atout.
Ãtre en mesure de gérer des renseignements confidentiels.
Posséder dâexcellentes aptitudes en gestion du temps et avoir un bon sens de lâorganisation.
Posséder de solides capacités de raisonnement et dâanalyse, être en mesure de résoudre des problèmes et dâagir à titre de médiateur dans les situations difficiles.
Ãtre motivé, curieux et capable de travailler de façon autonome, avec un minimum de supervision.
Posséder dâexcellentes habiletés interpersonnelles. Avoir lâesprit dâéquipe et être en mesure de travailler en collaboration avec les employés des autres services.
Faire preuve de souplesse, être débrouillard et être ouvert au changement.
Ãtre en mesure de gérer des tâches qui constituent une priorité absolue dans un environnement changeant.
Effectuer des recherches et en communiquer les résultats de manière efficace.
Avoir un grand intérêt pour le perfectionnement et lâapprentissage continu.
Présenter dâexcellentes habiletés de communication à lâoral comme à lâécrit.
Posséder des connaissances approfondies des applications de la suite MS Office (Excel, Word, Outlook).
Avoir suivi une formation des associations LOMA (Life Office Management Association) ou HIAA (Health Insurance Association of America) constitue un atout.
Note: Internal posting will close on March 18, 2024.
Express Scripts Canada is a Cigna company
Express Scripts Canada is a subsidiary of Express Scripts, a Cigna company. Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, wellbeing and peace of mind of those we serve. Cigna offers an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioural health, pharmacy, vision, supplemental benefits, and other related products.
About Express Scripts Canada
Express Scripts Canada is a leading health benefits manager and has been recognized as one of the most innovative. Our clients include Canada's leading insurers, third party administrators and governments. We work with these clients to develop industry-leading solutions to deliver superior healthcare in a cost-controlled environment. We provide Active Pharmacy⢠services to more than 7 million Canadian patients and adjudicate more than 100 million pharmacy, dental, and extended health claims annually. Through our proprietary consumer intelligence, clinical expertise, and patients-first approach, we promote better health decisions for plan members, while managing and reducing drug benefit costs for plan sponsors.
It will be a condition of employment that the successful candidate obtains an Enhanced Reliability Clearance from the Federal Government. The candidate will be required to provide supporting documentation to receive clearance if required.
We offer a competitive salary and benefits package, along with a positive work environment built on solid corporate values, integrity, mutual respect, collaboration, passion, service and alignment.
We are an equal opportunity employer that promotes a diverse, inclusive and accessible workplace. By embracing diversity, we build a more effective organization that empowers our employees to be the best that they can be.
We are committed to creating a working environment that is barrier-free and we are prepared to provide accommodation for people with disabilities.
If you require accommodation in completing the online application process, please email: eschr2@express-scripts.com Do not email eschr2@express-scripts.com for an update on your application or to provide your resume as you will not receive a response.
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