Pharmacy Claims Auditor

3 weeks ago

Mississauga, Ontario, Canada The Cigna Group Full time

About the Role:

The Pharmacy Claims Auditor will play a critical 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 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.

Requirements:

  • 2-5 years 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.

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, behavioral 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 are prepared to provide accommodation for people with disabilities.

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