Pharmacy Claims Auditor

4 weeks ago

Mississauga, Ontario, Canada Cigna Health and Life Insurance Company Full time
Pharmacy Claims Auditor Job Description

We are seeking a highly skilled Pharmacy Claims Auditor to join our team at Cigna Health and Life Insurance Company. As a Pharmacy Claims Auditor, you will play a critical role in ensuring the integrity of health claims and maintaining a network of providers through diligent review and education.

Key Responsibilities:

  1. Conduct various types of audits across Canada to validate that providers are compliant with benefit plan design and professional practice regulations.
  2. Use analytical and investigative skills to identify trends observed from claim reviews and ensure that audit techniques evolve to remain effective in managing risk for customers.
  3. Communicate with providers to gather information for audits, educate on claim submission practices, and respond to queries regarding audit results.
  4. Prepare, coordinate, and travel to conduct on-site audits at the provider's location, and complete post on-site audit activities.
  5. Compile and produce audit reports that are detailed and unbiased.
  6. Perform self and peer-review to ensure accuracy and quality of claim reviews.
  7. 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.
  8. Identify trends observed from claim reviews and provide recommendations for risk criteria changes and/or candidates for a desk or on-site audit.

Requirements:

  1. 2-5 years recent retail pharmacy experience with working knowledge of pharmacy software.
  2. Valid driver's license and ability to travel in Canada, range of 5-15% of time.
  3. Graduate of an accredited pharmacy education program.
  4. In-depth knowledge of pharmacy benefits, reimbursement, and pharmacy regulations.
  5. Previous audit/investigation experience.
  6. Flexible, resourceful, with a mindset that embraces and champions change.
  7. Proficiency in MS Office (Excel, Word, Outlook).
  8. Bilingualism (French & English) is an asset.
  9. LOMA or HIAA training would be an asset.

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. If you require accommodation in completing the online application process, please email: eschr2@express-scripts.com. At Cigna Health and Life Insurance Company, we're dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers, and patients.

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