Pharmacy Claims Auditor - Express Scripts Canada

The Cigna Group

Jul 15

Applications are closed

Job
Full-time
Junior, Mid & Senior Level
Healthcare
Hospitality & Retail
Mississauga

Requirements

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 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

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

FAQs

What are the essential functions of a Pharmacy Claims Auditor at Express Scripts Canada?

The essential functions of a Pharmacy Claims Auditor at Express Scripts Canada include performing claim verifications, desk and/or on-site audits, communicating with providers to gather information and educate on claim submission practices, assessing provider documentation for compliance with benefit plan design and provincial legislation, calculating adjustments for claim transactions, preparing and conducting on-site audits, producing detailed and unbiased audit reports, tracking audit activity and summarizing results, identifying trends from claim reviews, providing recommendations for risk criteria changes, responding to customer inquiries, and other duties as assigned.

What qualifications are required for the Pharmacy Claims Auditor position at Express Scripts Canada?

Qualifications for the Pharmacy Claims Auditor position at Express Scripts Canada include 2-5 years of recent retail pharmacy experience, knowledge of pharmacy software, a valid driver's license and willingness to travel in Canada, a graduate of an accredited pharmacy education program with R Ph.T. designation preferred, in-depth knowledge of pharmacy benefits, reimbursement, and regulations, previous audit/investigation experience, ability to manage confidential information, effective time management and organizational skills, critical thinking and problem-solving abilities, ability to work independently and as part of a team, flexibility and adaptability to change, excellent communication skills, proficiency in MS Office, bilingualism in French and English as an asset, and LOMA or HIAA training as a bonus.

The Cigna Group

Science & Healthcare

Industry

10,001+

Employees

Mission & Purpose

The Cigna Group is a global health company committed to creating a better future built on the vitality of every individual and every community. We relentlessly challenge ourselves to partner and innovate solutions for better health. The Cigna Group includes products and services marketed under Cigna Healthcare, Evernorth Health Services or its subsidiaries. The Cigna Group maintains sales capabilities in more than 30 countries and jurisdictions, and has more than 190 million customer relationships around the world.