Pharmacy Claims Investigator

Reporting to the Audit Program Manager, the incumbent will be responsible identifying and investigating pharmacy, dental and EHC providers, plan members, and prescribers for fraud, waste, and abuse risks associated to ESC’s clients. Using critical thinking skills and data analytics, the incumbent will complete complex investigational audits reviews in order to correct risks identified and protecting client’s health benefit plans assets, and present findings both verbally and in writing to key internal and external stakeholders. In addition, the Claims Investigator will participate in identifying and recommending policy, and procedures, and systems changes to enhance case development efficiency and quality of cases.

**Key Responsibilities**:
Analyze and evaluate potential fraud and abuse situations using corroboratory information obtained by correspondence with members, physicians, and pharmacies.

Identify and investigate cases of suspected fraud and high abuse for assigned clients. Develop these cases in compliance with any applicable policies, procedures, or regulatory requirements.

Prepare formal and thorough written reports to upper management, and clients, expressing the findings of completed investigations.

Prepare for and take lead role in client communications, including conference calls and on-site meetings, to present status updates of ongoing issues, results of completed investigations, etc., for assigned clients.

Identify and perform special projects.

**Qualifications**:
Bachelor’s degree or equivalent work experience

2-5 years of relevant experience as a pharmacy technician, health care professional, or data analyst

Certified Pharmacy Technician, Certified Fraud Examiner, or similar certification strongly desired

Ability to work well with senior management and high level external contacts, handle sensitive or confidential information is critical, work with minimum management oversight on multiple projects with competing priorities, Ability to work a flexible schedule to accommodate project deadlines.

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.