Extended Health Care Claims Auditor - Express Scripts Canada

Cigna Healthcare • Mississauga, ON

4d • CA$31 - CA$33 • Hybrid

About The Position

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. This role is particularly well-suited for individuals with a background as a Pharmacy Assistant or Pharmacy Technician who are looking to leverage their clinical knowledge in a dynamic, insight-driven role.

Requirements

• 2-5 years recent experience in a health care environment
• Graduate of an accredited pharmacy education program; RPhT. designation is preferred
• Valid driver’s license and ability to travel in Canada, range of 20-30% of the time
• In-depth knowledge of extended healthcare benefits, reimbursement and extended health care regulations is an asset
• Previous audit/investigation experience in the healthcare industry is an asset
• Experience with working with data and reports, with the ability to analyze information and identify inconsistencies.
• 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 minimal 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

Nice To Haves

• RPhT. designation is preferred
• In-depth knowledge of extended healthcare benefits, reimbursement and extended health care regulations is an asset
• Previous audit/investigation experience in the healthcare industry is an asset
• Bilingualism (French & English) is an asset
• LOMA or HIAA training would be an asset

Responsibilities

• 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 enrolment agreement, benefit plan design and provincial regulations.
• 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
• Identify trends observed from claim reviews and provide recommendations for risk criteria changes and/or candidates for a desk or on-site audit.
• 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

Benefits

• Competitive compensation
• benefits
• pension plan
• Career development and advancement opportunities
• A culture that celebrates innovation and collaboration
• Flexible work options and wellness programs
• competitive salary and benefits package
• positive work environment built on solid corporate values, integrity, mutual respect, collaboration, passion, service and alignment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree