Pharmacy Claims Auditor

4 weeks ago

Mississauga, Ontario, Canada The Cigna Group Full time

The Pharmacy Claims Auditor role is a critical component of the Business Integrity team at The Cigna Group. As a key member of this team, you will be responsible for conducting audits across Canada to ensure that healthcare providers are compliant with benefit plan design and professional practice regulations. Your analytical and investigative skills will be essential in identifying trends and ensuring that audit techniques evolve to remain effective in managing risk for our customers.

Key Responsibilities:

  • Perform claim verifications, desk and/or on-site audits to ensure compliance with regulatory requirements
  • Communicate with providers to gather information for audits and educate on claim submission practices
  • Assess provider documentation to ensure compliance with The Cigna Group's provider agreement and benefit plan design
  • Calculate adjustments required to correct claim transactions
  • Prepare and coordinate on-site audits 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 for department statistics
  • Identify trends and provide recommendations for risk criteria changes and/or candidates for a desk or on-site audit

Requirements:

  • 2-5 years recent retail pharmacy experience with working knowledge of pharmacy software
  • Valid driver's license and ability to travel in Canada (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

About The Cigna Group:

The Cigna Group is a global health service company dedicated to improving the health, wellbeing, and peace of mind of those we serve. We offer 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.

Why Join Us:

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.

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