Pharmacy Risk Advisor - Express Scripts Canada

Reporting to the Fraud Waste and Abuse (FWA) Pharmacy Investigations Manager, the successful candidate will be responsible for profiling providers, assessing risk, prioritizing and assigning audits and investigations to the team. The FWA Pharmacy Risk Advisor will be working closely with investigators to perform quality assurance on all audits and investigations. The FWA Pharmacy Risk Advisor will also ensure that client commitments and required service standards are met. The successful candidate will also be responsible for developing strategies to proactively detect FWA activities using their analytical and investigative skills, along with their practice and knowledge of provincial benefit coverage to identify trends observed from claim reviews. The Advisor will ensure that the audit techniques evolve to remain effective in managing risk for ESC and its clients. ESSENTIAL FUNCTIONS: Profile providers leveraging internal tools and external referrals to identify potential fraud, waste and abuse risks nationwide.Conduct risk assessments to prioritize audits and investigations, and assign them to the team of investigators.Ensure the delivery of high-quality audit reports.Monitor quality assurance activities and provide regular summaries of results for department statistics.Deliver evidence-based research to support discussions and decisions around audit application.Support the FWA team in responding to provider inquiries, legal inquiries and escalations.Continuously review and provide recommendations regarding claims verification risk criteria to ensure Express Scripts Canada is proactively identifying known industry risks for customers.Collaborate with data analysts to analyze claims data and drug trends to forecast areas of program risk.Work with leadership to review FWA program to maximize program potential.Review provider claims reports to identify abnormal or inconsistent claims submissions.Collaborate with FWA Pharmacy Investigations Manager to consult with internal and external stakeholders regarding FWA activities and support in customer-facing meetings.Recommend incremental and continuous improvement ideas that will increase ability to prevent and manage risk that will bring the most value to customers.Support communication protocols with providers to achieve response and resolution of FWA related issues.Maintain and revise, as necessary, department standards and procedures, in keeping with provincial provider regulations and practices.Other duties and special projects as assigned. QUALIFICATIONS: 5+ years of experience in pharmacy audit/investigation experience.Post-secondary degree.Graduation from an accredited pharmacy education program is an asset.R Ph.T. designation is an asset.Certified Fraud Examiner (CFE) Certification is an asset.Strong focus on quality and accuracy.In-depth knowledge of pharmacy benefits and reimbursement.Knowledge of provincial and federal pharmacy regulations and legislative requirements.Demonstrated interpersonal skills to facilitate change management.Team player and ability to work cross-functionally with other departments.Excellent time and resource management skills.Proven ability to manage competing priorities in a fast-paced environment.Strong focus on customer service and presentation skills.Detail-oriented with proven high-level verbal and written communication skills.Demonstrates and applies integrity in all aspects of work.Knowledge of Microsoft Office software (Word, Excel and PowerPoint). #J-18808-Ljbffr