Pharmacy Claims Auditor (12 Month Contract) - Express Scripts Canada

Pharmacy Claims Auditor (12 Month Contract) - Express Scripts CanadaApplyRemote Type: HybridLocation: Mississauga, ONTime Type: Full timePosted on: Posted YesterdayJob Requisition ID: 24013360The 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 for conducting 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.NOTE: This is a 12-month contract position with a possibility of extension.ESSENTIAL FUNCTIONS:Perform claim verifications, desk and/or on-site audits.Communicate with providers to gather information for audits, educate on claim submission practices, and respond to queries regarding 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 audits 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 the 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.QUALIFICATIONS:2-5 years recent retail pharmacy experience with working knowledge of pharmacy software.Valid driver’s license and ability to travel in Canada, range of 5-15% of time.Graduate of an accredited pharmacy education program; R Ph.T. designation is preferred.In-depth knowledge of pharmacy benefits, reimbursement, and pharmacy regulations.Previous audit/investigation experience.Ability to manage confidential information.Effective time management and organizational skills.Strong critical thinking skills with the 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.**Internal applicants should apply by October 17, 2024**Express Scripts Canada is a Cigna company.It will be a condition of employment that the successful candidate obtains an Enhanced Reliability Clearance from the Federal Government. The candidate will be required to provide supporting documentation to receive clearance if required.We offer a competitive salary and benefits package, along with a positive work environment built on solid corporate values, integrity, mutual respect, collaboration, passion, service, and alignment.We are an equal opportunity employer that promotes a diverse, inclusive, and accessible workplace. By embracing diversity, we build a more effective organization that empowers our employees to be the best that they can be.If you require accommodation in completing the online application process, please email: [email protected]. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.Doing something meaningful starts with a simple decision, a commitment to changing lives.At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers, and patients.Join us in driving growth and improving lives. #J-18808-Ljbffr