Job Description

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.ESSENTIAL FUNCTIONS:Perform claim verifications, desk and/or on-site auditsCommunicate with providers to gather information for audits, to educate on claim submission practices and to respond to queries in regards to audit resultsAssess provider documentation to ensure compliance with ESC\xe2\x80\x99s provider agreement, benefit plan design and provincial legislationCalculate the adjustments required to correct claim transactionsPrepare, coordinate and travel to conduct on-site audit at the provider\xe2\x80\x99s location, and complete the post on-site audit activitiesCompile and produce audit reports that are detailed and unbiasedPerform self and peer-review to ensure accuracy and quality of claim reviewsTrack audit activity and summarize results of claim analysis and recoveries on a daily and/or monthly basis for department statistics for presentation to customersIdentify 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 customersRespond to internal and external customer questions professionally, timely and accuratelyOther duties and responsibilities as assignedQUALIFICATIONS:2-5 years recent retail pharmacy experience with working knowledge of pharmacy softwareValid driver\xe2\x80\x99s license and ability to travel in Canada, range of 5-15% of timeGraduate of an accredited pharmacy education program; R Ph.T. designation is preferredIn-depth knowledge of pharmacy benefits, reimbursement and pharmacy regulationsPrevious audit/investigation experienceAbility to manage confidential informationEffective time management and organizational skillsStrong critical thinking skills with ability to analyze, problem-solve and mediate difficult situationsSelf-driven, curious, capable of working independently with minimal supervisionStrong interpersonal skills: team player and ability to work cross-functionally with other departmentsFlexible, resourceful, with a mindset that embraces and champions changeAbility to manage high priority tasks in a fast paced environmentAbility to research and effectively communicate findingsPassionate about development and continuous learningExcellent verbal and written communication skillsProficiency in MS Office (Excel, Word, Outlook)Bilingualism (French & English) is an assetLOMA or HIAA training would be an assetExpress Scripts Canada is a Cigna companyExpress 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 CanadaExpress 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