Job Description

The role of the Fraud, Waste & Abuse 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.

Location: Mississauga Head Office

Working Environment: Hybrid, 2 days/week on-site

ESSENTIAL FUNCTIONS:

Perform claim verifications financials, 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 experience in a health care environment Must have a diploma from a recognized post-secondary educational program in the health services field Valid driver's license and ability to travel in Canada, range of 20-30% of the time In-depth knowledge of extended healthcare benefits, reimbursement and extended health care regulations is an asset Experience in report writing Previous audit/investigation experience is an asset Experience in data analysis, financial analysis and statistics 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

Note: Internal posting will be closed October 2, 2025.

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(TM) 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.