Pharmacy Risk Advisor II

2 weeks ago


Mississauga, Ontario, Canada Cigna Full time
Job Description:

Cigna is seeking a highly skilled Pharmacy Risk Advisor to join our team in [location]. As a key member of our FWA (Fraud Waste and Abuse) team, you will play a critical role in identifying and mitigating risks within our pharmacy network.

Responsibilities:
  1. Provider Profiling: Utilize internal tools and external referrals to identify potential fraud, waste, and abuse risks nationwide.
  2. Risk Assessment: Conduct thorough risk assessments to prioritize audits and investigations, and assign them to the team of investigators.
  3. Audit Delivery: Ensure the delivery of high-quality audit reports that meet or exceed industry standards.
  4. Quality Assurance: Monitor quality assurance activities and provide regular summaries of results for department statistics.
  5. Evidence-Based Research: Deliver evidence-based research to support discussions and decisions around audit application.
  6. Escalation Support: Support the FWA team in responding to provider inquiries, legal inquiries, and escalations.
  7. Claims Verification: Continuously review and provide recommendations regarding claims verification risk criteria to ensure Cigna is proactively identifying known industry risks for customers.
  8. Data Analysis: Collaborate with data analysts to analyze claims data and drug trends to forecast areas of program risk.
Requirements:
  • Bachelor's degree in a relevant field (e.g., pharmacy, health administration).
  • At least 5 years of experience in pharmacy audit/investigation.
  • R Ph.T. designation is an asset.
  • Certified Fraud Examiner (CFE) Certification is an asset.
  • Strong focus on quality and accuracy.
  • In-depth knowledge of pharmacy benefits and reimbursement.
  • Knowledge of provincial and federal pharmacy regulations and legislative requirements.
  • Demonstrated interpersonal skills to facilitate change management.
  • Team player and ability to work cross-functionally with other departments.
  • Excellent time and resource management skills.
  • Proven ability to manage competing priorities in a fast-paced environment.
  • Strong focus on customer service and presentation skills.
  • Detail-oriented with proven high-level verbal and written communication skills.
  • Demonstrates and applies integrity in all aspects of work.
  • Knowledge of Microsoft Office software (Word, Excel, and PowerPoint).
Estimated Salary:

$90,000 - $120,000 per annum, depending on location and experience.



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