Senior Claims Auditor

The Senior Claims Auditor will lead all elements of Health PEI's Physician Claims Audit program and plan conduct and follow-up in-depth audits of physician billing. The position is intended to support Island Physicians through ensuring that billings are aligned with the current Master Agreement between MSPEI, the Government of PEI and Health PEI, helping to ensure efficient and effective use of the divisions medical insurance plans resources and providing accurate information to support evidence-based decisions or service provision and utilization.

Duties

• Provide analytical support to the Director of Fiscal Planning and Audit for billing information analysis requests, and provide advice and guidance to physician claims education and monitoring initiatives.
• Perform statistical analyses of claims data annually and identify and investigate unusual Physician claims patterns.
• Evaluate results of routine claims monitoring by fee code and Physician/Practitioner and identify and investigate unusual claims patterns or claims issues.
• Receive and investigate potential claims issues from management or other sources
• Prepare semi-annual plans for comprehensive audits of specific billing codes or Physician/Practitioner practices based on a risk-ranked analysis of the above information, with input and advice from the Audit Advisory Committee.
• Write and send introductory letters to physicians outlining the proposed date for each on-site audit.
• Prepare for and conduct in-person interviews with physicians and staff and observe the office practices (patient scheduling, drop-ins, documentation procedures etc.) in order to better understand current practices and to formulate billing practice comments, recommendations and support.
• Prepare letters to inform physicians of audit findings and provide recommendations to promote billing compliance, schedules of statistical analysis used to establish financial recovery, and a list of transactions audited detailing any adjustments.
• Plan claims-data analysis projects using input from claims monitoring, previous assessments and/or audit findings, and from other sources including management.
• Compile, calculate, and summarize data, using statistical methods when applicable, to complete pattern of practice analysis in order to identify physicians with unusual patterns.
• Investigate and evaluate unusual billing practices and patterns of practice, identify high-risk areas/cases, assess and evaluate the potential impacts and determine further course(s) of action.
• Respond, on an ongoing basis, to oral or written reports from Claims Education and Monitoring Specialist that highlight codes or practices where high error rates were found in claims monitoring and determine a further course of action (i.e. analysis of data, recommendation for education and/or audit).
• Other related duties to inform and improve physician claims and claims addition, as required.

Minimum Qualifications:

• Bachelor degree in Administration, Commerce or Arts with an accounting or auditing designation (CPA or CIA).
• Extensive (5+ years) of progressive experience in the field of internal or external auditing is required.
• Experience interpreting and applying government guidelines, policies, legislative documents, and complex payment agreements.
• Experience managing self and situations involving conflict with individuals.
• Basic law education or related experience in the law of contracts and fiduciary duties.
• Demonstrated equivalencies will be considered.
• Proficient in advanced financial statistical audit methodologies.
• Demonstrated advanced level Microsoft excel skills and analysis of complex data sets.
• Detail oriented, comprehensive and focused to ensure that records, notes and analyses are accurate and able to withstand scrutiny
• Superior critical thinking, problem solving, and analytical skills.
• Superior interpersonal skills and ability to deal with individuals on sensitive, complex, contentious and confidential billing matters.
• Demonstrated ability to communicate, orally and in writing, in a manner that conveys information that is clear, concise and timely, to a variety of audiences that persuades, convinces, educates, and promotes understanding.
• Independent and organized, proactive in order to ensure goals and objectives are met in a timely manner
• Innovative and highly motivated to enhance and improve the Division's auditing practes
• Working knowledge of PEI health sector
• Demonstrated experience in relationship building, collaboration, and team building skills
• Demonstrated proficiency working in a computerized environment
• Good previous work and attendance record.
• The successful applicant must provide a satisfactory criminal records check prior to beginning employment.

Other Qualifications:

• Experience or training in forensic audit techniques would be an asset
• Experience with Physician claims systems (Medigent CPS) and Electronic Health Records (Cerner) would be an asset.
• Additional relevant education and experience will be considered an asset.

Please Note: Please ensure the application clearly demonstrates how you meet the noted qualifications as applicants will be screened based on the information provided. We would like to thank all applicants for their interest; however, only those who are selected for an interview will be contacted.

This competition may be used to fill future job vacancies.

Salary Range:
$ $48.08 per hour (Level 19)

Bi-Weekly Hours:
75.0 Hours Bi-Weekly / Days / Occasional Evenings may be Required

Posting ID:
171016

Closing Date:
Friday November 21, 2025 at 4:00pm