Pharmacy Claims Auditor

4 weeks ago

Mississauga, Ontario, Canada The Cigna Group Full time

The Pharmacy Claims Auditor role at The Cigna Group is a critical position that requires a strong analytical mindset and attention to detail. As a key member of our Business Integrity team, you will be responsible for conducting audits across Canada to ensure the integrity of health claims and maintain a network of providers.

Key Responsibilities:

  • Perform claim verifications, desk and/or on-site audits 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 our provider agreement, benefit plan design, and provincial legislation.
  • Calculate adjustments required to correct claim transactions and prepare, coordinate, and travel to conduct on-site audits at the provider's location.
  • Compile and produce audit reports that are detailed and unbiased, and 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 that will bring 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.

Why Join Us:

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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