Pharmacy Claims Auditor

4 weeks ago

Mississauga, Ontario, Canada The Cigna Group Full time
Job Title: Pharmacy Claims Auditor

The Pharmacy Claims Auditor plays a crucial role in ensuring the integrity of health claims and maintaining a network of providers through diligent review and education. This position requires strong analytical and investigative skills, as well as in-depth knowledge of pharmacy benefits, reimbursement, and pharmacy regulations.

Key Responsibilities:
  • Conduct various types of audits across Canada to validate provider compliance with benefit plan design and professional practice regulations.
  • Communicate with providers to gather information for audits, educate on claim submission practices, and respond to queries regarding audit results.
  • Assess provider documentation to ensure compliance with ESC's provider agreement, benefit plan design, and provincial legislation.
  • Calculate adjustments required to correct claim transactions.
  • Prepare, coordinate, and travel to conduct on-site audits at the provider's location, and complete post-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 the ability to prevent and manage risk, bringing the most value to customers.
  • Respond to internal and external customer questions professionally, timely, and accurately.
Qualifications:
  • 2-5 years of recent retail pharmacy experience with working knowledge of pharmacy software.
  • Valid driver's license and ability to travel in Canada, range of 5-15% of time.
  • Graduate of an accredited pharmacy education program; R Ph.T. designation is preferred.
  • In-depth knowledge of pharmacy benefits, reimbursement, and pharmacy regulations.
  • Previous audit/investigation experience.
  • 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).
  • Bilingualism (French & English) is an asset.
  • LOMA or HIAA training would be an asset.

Express Scripts Canada is a Cigna company, dedicated to improving the health, wellbeing, and peace of mind of those we serve. 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 are prepared to provide accommodation for people with disabilities.

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