Pharmacy Claims Auditor (12 Month Contract)

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.

NOTE : This is a 12 months contract position with a possibility of extension. This role is hybrid / remote.

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

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 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

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