- 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
- 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
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Pharmacy Claims Auditor - Mississauga, Canada - The Cigna Group
Description
The job profile for this position is Quality Review and Audit Senior Analyst, which is a Band 3 Senior Contributor Career Track Role.Excited to grow your career?
We value our talented employees, and whenever possible strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think the open position you see is right for you, we encourage you to apply
Our people make all the difference in our success.
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.
ESSENTIAL FUNCTIONS:
QUALIFICATIONS:
NOTE: Internal candidates should apply before April 5, 2024.
Please note that you must meet our posting guidelines to be eligible for consideration. Policy can be reviewed at this link.
