Pharmacy Claims Auditor - Mississauga - The Cigna Group

    The Cigna Group
    The Cigna Group Mississauga

    2 days ago

    Full time
    Description

    The role of the Business Integrity team is to enhance the Express Scripts Canada 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 for conducting various types of audits across Canada to validate that providers are compliant with benefit plan design and professional practice regulations.

    Key Responsibilities:

    • Perform claim verifications, desk and/or on-site audits
    • Communicate with providers regarding audit results, educate them on claim submission practices, and respond to queries
    • Evaluate provider documentation to ensure compliance with ESC's provider agreement, benefit plan design, and provincial legislation
    • Calculate adjustments required to correct claim transactions

    Auditors use analytical skills along with knowledge of pharmacy software and provincial benefit coverage to identify trends observed from claim reviews. They also evolve audit techniques remain effective in managing risk for ESC customers.


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