Job Description

Summary:

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.

Note: This is a 12 months contract opportunity with a possible extension.

Key Responsibility:

Perform claim verifications, desk and/or on-site audits for Dental, Vision and Mental Health benefits.

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 enrolment agreement, benefit plan design and provincial regulations.

Calculate the adjustments required to correct claim transactions

Prepare, coordinate and travel to conduct on-site audit at the provider\xe2\x80\x99s 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 dental office environment with working knowledge of dental software and fee codes

Valid driver\xe2\x80\x99s license and ability to travel in Canada, range of 20-30% of time

Graduate of post-secondary educational program either as a dental assistant or dental hygienist with a valid license

In-depth knowledge of dental benefits, reimbursement and dental regulations

Previous audit/investigation experience is an asset

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 candidate should apply before September 1, 2023.

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\xe2\x84\xa2 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: Do not email for an update on your application or to provide your resume as you will not receive a response.

Cigna