Prescription Drug Claims Auditor

**Prescription Drug Claims Auditor (Hybrid Work Arrangement)**

**Preference is given to pharmacy assistants or technicians**

Orion Audit Limited has been conducting Prescription Drug, Extended Health Care, Dental, and Disability Group Benefits claims audits since 2005. We have quickly emerged as the industry leader and have a reputation for bringing strong governance and accountability to benefit plans across Canada. As a result, we conduct audits for some of the largest plans within Canada.

As a boutique firm, we strongly value individual contributions from each team member, providing autonomy in your technically skilled work. As a member of this specialized team, you can expect to be challenged in a meaningful way, allowing your creativity and passion for Prescription Drug Benefits to shine.

**Role Summary**

To conduct high-quality and detailed Prescription Drug Claim Audits on behalf of our clients. This includes analyzing Prescription Drug claims data, detecting and evaluating patterns, trends, and anomalies, and turning them into meaningful insights and recommendations for our clients through formal written reports and presentations.

A component of this role includes supporting our consulting team as a technical resource. Conducting technical reviews, insights, and recommendations for the Prescription Drug portion of our client's Group Benefits plans. Keeping up with key industry trends, new products, and processes is highly valued.

**What You Will be Doing**
- Conduct high quality, detailed, Drug claim audits; evaluate adjudication processes, error rate, test plan eligibility, and adherence to the insurance contracts
- Review, interpret, and summarize plan designs from insurance contracts
- Analyze drug claim data, and effectively detect and evaluate patterns, trends, and anomalies
- Identify opportunities, solutions, and recommendations to improve claims administrative processes with a focus on cost savings and risk management
- Prepare written reports; technical writing outlining observations and findings of claim audits
- Participate in the preparation and presentation of audit insights, findings, and recommendations:

- to current or prospective clients; and
- to generate new business opportunities

**What You Bring to This Role**
- Demonstrated knowledge and experience of Group Benefits Prescription Drug plans, with experience in retail or hospital pharmacy, pharmacy operations, drug claim billing expertise, or insurance industry
- Five to ten years of experience in processing practices of drug claims for Group Benefit plans at a TPA, PBM and/or insurance company, and claims processing in a pharmacy setting
- Strong working knowledge of Provincial Pharmacare Programs; including both private and public reimbursement models
- Solid background and familiarity with:

- Industry best practices
- Coordination of benefits
- Internal audit processes and fraud detection
- Prescription Drug plan design
- Drug Utilization Reviews
- Drug pricing and fee structure
- Brand and generic drugs
- Narcotic controls
- Results oriented; ability to balance multiple priorities
- Comfortable speaking/presenting information in a group setting
- Ability to manage fluctuating and unpredictable workload
- Strong research, problem solving, and decision-making skills
- Demonstrated strong written and verbal communication skills

**Assets**
- Recent retail, commercial, or hospital pharmacy adjudication/processing experience is strongly preferred
- Experience in adjudicating Extended Health Care and prescription Drug claims at an insurer or TPA or PBM
- Experience with Pharmacy Benefits Management, drug plan design, or drug reimbursement models
- Experience in Group Benefits risk management, including fraud detection and prevention strategies

**What We Bring to The Table**

At Orion, we understand there are no shortcuts to any place worth going, which is why we recognize our team members' dedication and unique contributions. Our success is largely attributed to our diverse team of specialists, one of the reasons we offer competitive salaries. Since compensation isn’t just focused on salary, we also provide:

- Flexibility to customize compensation, including vacation time, based on what matters to you most
- Flexible work hours, since life can still happen between 9-5
- Flexible work-from-home options, such as working remotely from home or cottage. The office premise is in the Waterloo Region, where some in-office time may be required. Occasional travel to our Kleinburg office may also be required
- Comprehensive Health Benefits package, since a healthy employee is a happy one
- Retirement contributions: we believe in planning for your future as much as you do
- Allowances for continued learning and educational expenses
- Reimburse expenses such as your cell phone and reasonable office supplies
- Opportunity to design, create, and develop this role further
- Opportunities for growth and to take on progressively increa