Pharmacy Claims Auditor, 12 Months Contract - Express Scripts Canada

The Cigna Group•Mississauga, ON

32d•$31 - $33•Hybrid

About The Position

Express Scripts Canada (ESC) is a leading health benefits management company. Serving over 12 million members, we help insurance carriers, third party administrators, and the public sector optimize the value of health benefits by linking the talent and professional expertise of our people with leading edge information management systems and technology. ESC is a wholly owned subsidiary of Express Scripts Inc., one of the largest pharmacy benefit management (PBM) companies in North America, part of The Cigna Group (NYSE: CI), a global health company. Together, we deliver innovative, cost-effective solutions that improve access, affordability, and health outcomes for Canadians. 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.

Requirements

2-5 years recent retail pharmacy experience with working knowledge of pharmacy software
Graduate of an accredited pharmacy education program; RPhT designation is preferred
In-depth knowledge of pharmacy benefits, reimbursement and pharmacy regulations
Previous audit/investigation experience
Valid driver’s license and ability to travel in Canada, range of 5-15% of time
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)

Nice To Haves

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 ESC’s provider agreement, benefit plan design and provincial legislation
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