Health and Drug Claims Consultant

At Equitable, we believe work should be a place where you feel supported, inspired, and empowered to grow. In our caring and collaborative environment, your curiosity is encouraged, your passion is recognized, and your contributions truly matter. Together, we create meaningful impact; for our clients, our communities, and each other.

Position Title: Health and Drug Claims Consultant
Reports To: Director, Pharmacy Benefits
Department: Group
Term:  Permanent Full-Time

Work Arrangements: This is a hybrid role. You will work in our office in Waterloo, ON a minimum of two (2) assigned, consecutive days every other week, plus a fifth (5th) assigned day per month. You are welcome to work from the office more than the minimum requirement and there may be some roles that are required to work in our office more than the minimum requirement.

 

The Opportunity:  At Equitable, our focus is on making a meaningful impact in the lives of Canadians by putting clients at the heart of everything we do. We lead with empathy, act with intention, stay curious, and support one another every step of the way. If you're looking for purpose-driven work in a collaborative and inclusive environment where your voice is heard, and your growth is encouraged we'd love to connect.

At Equitable, we realize that your work life is not just about performing a job; it's about being part of a workplace that helps you grow and reach your full potential. Within our friendly and collaborative work environment, we recognize that the key to our growth and success is a dedicated, motivated and client-responsive staff. We are looking for a passionate and experienced Drug Claims Consultant to support our Pharmacy Benefits organization under the Group Claims and Administration umbrella.

Join one of the Waterloo Area's Top Employers for 2025 and Southwestern Ontario's Top Employers for 2024 and be part of something that matters.

What you will be doing:

• Act as a resource to internal departments on pharmacy services, by analyzing and explaining drug adjudication, health industry news and the impact of legislative changes
• Manage high profile drug eligibility requests with urgency to ensure client care is prioritized
• Identify and communicate alternate funding streams for products and services
• Contribute to implementing internal process changes for drug plan management as well as identify opportunities for process improvements to gain efficiencies and reduce errors 
• Provide advice on emerging issues and leading practices related to health & drug benefit management 
• Support strategic planning sessions through identifying opportunities for operational improvements as well as addressing key industry trends 
• Provide recommendations in best practices in health & drug benefit management techniques, formulary design and cost containment strategies for drug utilization. 
• Participate on industry committees (CLHIA, GIPC, Brogan, etc.) to acquire and influence industry practices and reconcile any inconsistencies presented 
• Participate in projects and provide expertise and recommendations
• If required, act as a project lead for pharmacy led initiatives and as a business lead in Group Benefit initiatives 
• Make recommendations on plan sponsor contract content, updates 
• Act as domain subject matter expert for trainers or individuals, and provide education as required to cross-functional teams such as Underwriting, Group Sales, Group Health Claims, etc. 
• Work cross functionally within Group Benefits and with Underwriting, Group Issue, Group Sales & Group Marketing 
• Execute claims adjudication changes including leading cross-functional project teams 
• Provide support and expertise to Health, Dental and Investigations team 
• Partner with Vendors on specific initiatives 
• As SME on Equitable products and systems, work with Pharmacy Benefits Manager (PBM) operations team to ensure that projects and claims are functioning appropriately  
• Research, review and provide recommendations on eligibility of new products/services 
• SME for complex and escalated cases, business development/marketing support 

What you will bring:

• An innovative approach to problem solving with a keen understanding of client needs.
• Technical expertise you'll use to lead projects related to drug claim solution design and adjudication.
• A sense of curiosity to stay current with industry trends and legislative changes, ensuring compliance with federal and provincial regulations.
• Confidence and experience to support the management of complex, and sometime contentious claim situations.
• The ability to see things from the client's point of view as you actively participate in key projects with partners in Product and Operations.
• Knowledge gained in your career so far to support Group Sales Executives with claims decisions, product education, and business processes awareness.
• Communication skills to clearly convey complex drug, treatment, eligibility, and process information directly to internal partners and plan members.
• A collaborative approach to work closely with our Pharmacy Benefits Manager partner, and other industry stakeholders.
• 3-5 years of experience in Group Benefits or a related field.
• 3-5 years of pharmacy experience or a related field (preferred)
• Pharmacy technician education/qualification (preferred)
• Understanding of Group Benefit contracts and drug plan design.
• Excellent organizational skills, including planning and execution of business deliverables.
• Strong verbal and written communication skills.
• Proficiency in Microsoft Office, including Word, Excel, and PowerPoint.
• Project management experience and the ability to represent the business area.

What's in it for you:

• A workplace where care, passion, and curiosity aren't just values, they're how we work, grow, and succeed together every day.
• A healthy work-life balance with employee wellness top of mind
• Annual bonus program, annual vacation allowance, and company-paid benefits program
• Generous vacation package with one volunteer day to give back to a charity of your choice
• Immediate enrollment in the company's pension program with employer matching
• Employee resource groups that support an inclusive work environment
• Tuition support and specialized program assistance
• An onsite full-service cafeteria with a variety of daily options
• Discounts on company products and services, and access to exclusive employee perks
• Regular EQ Together events focused on company togetherness and collaboration
  

As part of the recruitment process, candidates may be asked to complete an assessment and will be required to undergo background screening, in accordance with company policy.

This position is available due to an existing vacancy.

We're dedicated to inclusive and accessible hiring practices. If you require accommodations or alternative formats, please contact us at

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