Pharmacy Claims Auditor - Express Scripts Canada Job at Cigna
The role of the FWA team is to proactively detect and address risks in a timely manner that effectively manages the financial risk and reputation of Express Scripts Canada (ESC) customers. 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.
Note: This is a remote position and required some travelling within Canada as an Auditor.
Essential Functions:
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
Work with both internal and external stakeholders to address client’s inquiries, gather, collect information, and coordinate investigations
Provide testimonials for legal proceedings
Continuously seek opportunities to create efficiencies within processes and drive value for the program
Assist in mentoring and developing team members
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 strongly preferred
In-depth knowledge of pharmacy benefits, reimbursement and pharmacy regulations
Display high levels of curiosity, integrity, honesty, tact, objective judgement, resiliency and self-motivation
Previous audit/investigation experience is an asset
Ability to manage sensitive or confidential information
Effective time management and organizational skills
Strong critical thinking skills with ability to analyze, problem-solve and mediate difficult situations
Self-driven and, 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
Work well in high pressure environments with urgent deadlines
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
NOTE: Internal candidates should apply before December 19, 2022.
Express Scripts Canada is a Cigna company
Express Scripts Canada is a subsidiary of Express Scripts, a Cigna company. Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, wellbeing and peace of mind of those we serve. Cigna offers an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioural health, pharmacy, vision, supplemental benefits, and other related products.
About Express Scripts Canada
Express Scripts Canada is a leading health benefits manager and has been recognized as one of the most innovative. Our clients include Canada's leading insurers, third party administrators and governments. We work with these clients to develop industry-leading solutions to deliver superior healthcare in a cost-controlled environment. We provide Active Pharmacy™ services to more than 7 million Canadian patients and adjudicate more than 100 million pharmacy, dental, and extended health claims annually. Through our proprietary consumer intelligence, clinical expertise, and patients-first approach, we promote better health decisions for plan members, while managing and reducing drug benefit costs for plan sponsors.
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.
We are committed to creating a working environment that is barrier-free and we are prepared to provide accommodation for people with disabilities.
If you require accommodation in completing the online application process, please email: eschr2@express-scripts.com Do not email eschr2@express-scripts.com for an update on your application or to provide your resume as you will not receive a response.
Please Note :
clearvoyant.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, clearvoyant.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.
Note: This is a remote position and required some travelling within Canada as an Auditor.
Essential Functions:
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
Work with both internal and external stakeholders to address client’s inquiries, gather, collect information, and coordinate investigations
Provide testimonials for legal proceedings
Continuously seek opportunities to create efficiencies within processes and drive value for the program
Assist in mentoring and developing team members
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 strongly preferred
In-depth knowledge of pharmacy benefits, reimbursement and pharmacy regulations
Display high levels of curiosity, integrity, honesty, tact, objective judgement, resiliency and self-motivation
Previous audit/investigation experience is an asset
Ability to manage sensitive or confidential information
Effective time management and organizational skills
Strong critical thinking skills with ability to analyze, problem-solve and mediate difficult situations
Self-driven and, 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
Work well in high pressure environments with urgent deadlines
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
NOTE: Internal candidates should apply before December 19, 2022.
Express Scripts Canada is a Cigna company
Express Scripts Canada is a subsidiary of Express Scripts, a Cigna company. Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, wellbeing and peace of mind of those we serve. Cigna offers an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioural health, pharmacy, vision, supplemental benefits, and other related products.
About Express Scripts Canada
Express Scripts Canada is a leading health benefits manager and has been recognized as one of the most innovative. Our clients include Canada's leading insurers, third party administrators and governments. We work with these clients to develop industry-leading solutions to deliver superior healthcare in a cost-controlled environment. We provide Active Pharmacy™ services to more than 7 million Canadian patients and adjudicate more than 100 million pharmacy, dental, and extended health claims annually. Through our proprietary consumer intelligence, clinical expertise, and patients-first approach, we promote better health decisions for plan members, while managing and reducing drug benefit costs for plan sponsors.
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.
We are committed to creating a working environment that is barrier-free and we are prepared to provide accommodation for people with disabilities.
If you require accommodation in completing the online application process, please email: eschr2@express-scripts.com Do not email eschr2@express-scripts.com for an update on your application or to provide your resume as you will not receive a response.
Please Note :
clearvoyant.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, clearvoyant.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.