Bilingual Dental Auditor-express Scripts Canada

5 months ago

Mississauga, Canada The Cigna Group Full time

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 provider’s 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
- 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 driver’s 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 mínimal 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 assetLe rôle de l’équipe de vérification en matière de fraude, de gaspillage et d’abus consiste à offrir des services à valeur ajoutée aux clients d’Express Scripts Canada en veillant à l’intégrité 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 d’effectuer 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 d’analyse et d’enquête ainsi que ses connaissances et son expérience en matière de couverture des soins de santé à l’échelle provinciale afin de déceler des tendances dans les demandes de règlement. Il s’assure également que les techniques de vérification évoluent afin de demeurer efficaces dans la gestion des risques auxquels les clients d’Express Scripts Canada sont exposés.

**Responsabilités principales**
- Effectuer l’examen 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.
- S’assurer que les documents transmis par les fournisseurs respectent l’entente qu’ils ont conclue avec Express Scripts Canada, ainsi que les dispositions des régimes et les lois provincial

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