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Pharmacy Claims Auditor

2 weeks ago

Mississauga, Canada The Cigna Group Full time

The role of the Business Integrity team is to enhance the Express Scripts Canada (ESC) value proposition for customers to ensure the integrity of health claims while maintaining a network of providers through diligent review and education. The Auditor is responsible to conduct various types of audits across Canada to validate that providers are compliant with benefit plan design and professional practice regulations. The Auditor uses their analytical and investigative skills along with their practice and 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 ESC customers.

**ESSENTIAL FUNCTIONS**:

- 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 ESC’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
- 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

**QUALIFICATIONS**:

- 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 mínimal 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

**Express Scripts Canada is a Cigna company**

Express Scripts Canada is a subsidiary of Express Scripts, a Cigna company. Cigna Corporation (NYSE: CI) 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.

**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.

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.