Pharmacy Claims Auditor

3 weeks ago

Mississauga, Ontario, Canada The Cigna Group Full time

The role of the Business Integrity team at The Cigna Group is to enhance the value proposition for customers by ensuring the integrity of health claims while maintaining a network of providers through diligent review and education. The Auditor is responsible for conducting various types of audits across Canada to validate that providers are compliant with benefit plan design and professional practice regulations. The Auditor uses analytical and investigative skills along with their knowledge of provincial benefit coverage to identify trends observed from claim reviews and to ensure that the audit techniques evolve to remain effective in managing risk for customers.

Key Responsibilities:

  • Perform claim verifications, desk and/or on-site audits
  • Communicate with providers to gather information for audits, to educate on claim submission practices and to respond to queries in regards to audit results
  • Assess provider documentation to ensure compliance with The Cigna Group's provider agreement, benefit plan design and provincial legislation
  • Calculate the adjustments required to correct claim transactions
  • Prepare, coordinate and travel to conduct on-site audit at the provider's location, and complete the post on-site 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 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
  • Other duties and responsibilities as assigned

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. Cigna offers 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.

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 we are prepared to provide accommodation for people with disabilities.

  • Pharmacy Claims Auditor

    4 weeks ago

    Mississauga, Ontario, Canada The Cigna Group Full time

    Job Title: Pharmacy Claims AuditorThe Pharmacy Claims Auditor plays a crucial 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 pharmacy...

  • Pharmacy Claims Auditor

    1 week ago

    Mississauga, Ontario, Canada The Cigna Group Full time

    Job Title: Pharmacy Claims Auditor - Integrity SpecialistJob Summary:The Pharmacy Claims Auditor - Integrity Specialist position is a key role within our organization, responsible for conducting audits and investigations to ensure compliance with our pharmacy benefit management policies and procedures. This individual will work closely with our pharmacy team...

  • 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...

  • 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...

  • Pharmacy Claims Auditor

    4 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...

  • Pharmacy Claims Auditor

    2 weeks ago

    Mississauga, Ontario, Canada Cigna Health and Life Insurance Company Full time

    Pharmacy Claims Auditor Role OverviewAs a member of the Business Integrity team at Cigna Health and Life Insurance Company, the Pharmacy Claims Auditor will play a critical role in enhancing the value proposition for customers by ensuring the integrity of health claims. The successful candidate will be responsible for conducting various types of audits...

  • Pharmacy Claims Auditor Specialist

    7 days ago

    Mississauga, Ontario, Canada Express Scripts Inc. Full time

    About This OpportunityExpress Scripts Canada is seeking a talented Pharmacy Claims Auditor to join our Business Integrity team. As a key member of our team, you will play a crucial role in enhancing our value proposition for customers by ensuring the integrity of health claims and maintaining a network of providers through diligent review and education.Key...

  • Claims Auditor Specialist

    1 day ago

    Mississauga, Ontario, Canada Crawford & Company Full time

    Job Title: Claims Auditor SpecialistCrawford & Company is seeking an experienced Claims Auditor Specialist to join our team in Waterloo or Mississauga, Canada. This role offers flexible working arrangements, including in-office, hybrid, or fully remote options.The successful candidate will play a key role in reviewing and improving our claim handling...

  • Insurance Claims Auditor

    3 weeks ago

    Mississauga, Ontario, Canada Crawford & Company Full time

    Position SummaryWe are seeking a skilled Claims Auditor to review and improve our current claim handling processes. The ideal candidate will have a minimum of 10 years of insurance P&C senior claims handling experience and 5 years of experience performing claims audits.Key ResponsibilitiesReview and analyze claim handling processes to identify gaps and areas...

  • Auditor - Compliance Specialist

    4 weeks ago

    Mississauga, Ontario, Canada Cigna Full time

    The Business Integrity team at Cigna is responsible for ensuring the integrity of health claims and maintaining a network of providers through diligent review and education. The Auditor plays a crucial role in conducting various types of audits across Canada to validate that providers are compliant with benefit plan design and professional practice...

  • Claims Auditor/Trainer Role

    1 day ago

    Mississauga, Ontario, Canada Crawford & Company Full time

    Why Crawford & Company?At Crawford & Company, we strive to be at the forefront of change, leveraging our unmatched global expertise and industry-leading technology to deliver exceptional results. As a Claims Auditor/Trainer, you will be part of a global network of professionals working together to help people through challenging times.We offer a dynamic work...

  • Pharmacy Assistant

    4 weeks ago

    Mississauga, Ontario, Canada SQ.1 Pharmacy Inc. Full time

    Job Title: Pharmacy Technical AssistantSQ.1 Pharmacy Inc. is seeking a detail-oriented and organized Pharmacy Technical Assistant to join our team. The ideal candidate will have a strong understanding of pharmacy operations and be able to maintain accurate records and inventories.Key Responsibilities:Bill Processing: Accurately bill third-party insurers for...

  • Claims Auditor/Trainer Position

    4 weeks ago

    Mississauga, Ontario, Canada Crawford & Company Full time

    Position SummaryWe are seeking a Claims Auditor/Trainer to review current claim handling processes, identify gaps, and make recommendations for process improvement. The successful candidate will create documentation and facilitate training sessions for optimal performance and improved audit results.RequirementsMinimum of 10 years of insurance P&C senior...

  • Pharmacy Support Specialist

    3 weeks ago

    Mississauga, Ontario, Canada SQ.1 Pharmacy Inc. Full time

    Job Summary: We are seeking a highly organized and detail-oriented Pharmacy Technical Assistant to join our team at SQ.1 Pharmacy Inc. The successful candidate will be responsible for maintaining inventories of medications and prescription records, processing claims, and maintaining supplies.Key Responsibilities:Maintain accurate and up-to-date records of...

  • Pharmacy Support Specialist

    2 weeks ago

    Mississauga, Ontario, Canada SQ.1 Pharmacy Inc. Full time

    Job Title: Pharmacy Technical AssistantJob Summary: We are seeking a skilled Pharmacy Technical Assistant to join our team at SQ.1 Pharmacy Inc. The successful candidate will be responsible for maintaining inventories of medications and prescription records, processing claims, and maintaining supplies.Responsibilities:Billing third party insurersMaintaining...

  • Pharmacy Assistant

    4 weeks ago

    Mississauga, Ontario, Canada SQ.1 Pharmacy Inc. Full time

    At SQ.1 Pharmacy Inc., we are seeking a detail-oriented Pharmacy Technical Assistant to join our team. The successful candidate will be responsible for maintaining accurate inventories of medications and prescription records of pharmaceutical products. This role also involves processing claims such as health insurance or workers compensation, as well as...

  • Pharmacy Support Specialist

    1 day ago

    Mississauga, Ontario, Canada SQ.1 Pharmacy Inc. Full time

    About the RoleWe are seeking a Pharmacy Technical Assistant to join our team at SQ.1 Pharmacy Inc.Job SummaryThe successful candidate will be responsible for assisting with various tasks related to pharmacy operations, including maintaining inventory, processing claims, and interpreting physician's specifications.Key ResponsibilitiesMaintain accurate and...

  • Pharmacy Support Specialist

    6 days ago

    Mississauga, Ontario, Canada SQ.1 Pharmacy Inc. Full time

    Job Summary:A dynamic individual with 7 months to 1 year of experience in a fast-paced pharmacy environment is sought after to fill the role of Pharmacy Support Specialist. In this position, you will be responsible for managing inventory, processing claims, and maintaining accurate records.Key Responsibilities:Billing third party insurers and ensuring timely...

  • Insurance Claims Auditor/Trainer

    4 weeks ago

    Mississauga, Ontario, Canada Crawford & Company Full time

    Why Crawford & Company?At Crawford & Company, we're dedicated to helping people through difficult times. Our team of passionate and compassionate professionals works together to deliver on our purpose of restoring lives, businesses, and communities. With over 80 years of unmatched global expertise and industry-leading technology, we're at the forefront of...

  • Pharmacy Assistant

    4 weeks ago

    Mississauga, Ontario, Canada SQ.1 Pharmacy Inc. Full time

    Job SummaryWe are seeking a detail-oriented Pharmacy Technical Assistant to join our team at SQ.1 Pharmacy Inc. The successful candidate will be responsible for maintaining accurate inventories of medications and prescription records, processing claims, and providing excellent customer service.Key ResponsibilitiesMaintain accurate and up-to-date records of...