Bilingual Dental Auditor-express Scripts Canada - Mississauga, Canada - The Cigna Group

The Cigna Group

Verified Company

Mississauga, Canada

1 week ago

Posted by:

Sophia Lee

beBee Recruiter

Description

The role of the Fraud, Waste and 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 Dental Benefit 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:

Perform claim verifications, desk and/or onsite 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 enrolment agreement, benefit plan design and provincial regulations.
Calculate the adjustments required to correct claim transactions
Prepare, coordinate and travel to conduct onsite audit at the provider's location, and complete the post onsite audit activities
Compile and produce audit reports that are detailed and unbiased
Perform self and peerreview 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
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:

25 years recent experience in a dental office environment with working knowledge of dental software and fee codes
Valid driver's license and ability to travel in Canada, range of 2030% of time
Graduate of postsecondary educational program either as a dental assistant or dental hygienist with a valid license
Bilingualism (French & English) is a must.
Experience in data analysis, financial and statistics.
Experience in report writing.
Indepth 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, problemsolve and mediate difficult situations
Selfdriven, curious, capable of working independently with mínimal supervision
Strong interpersonal skills: team player and ability to work crossfunctionally 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).
Life Office Management Association (LOMA) or Health Insurance Association of America (HIAA) training would be an assetLe rôle de l'équipe de vérification en matière de fraude, de gaspillage et d'abus consiste à offrir des services à valeur ajoutée aux clients d'Express Scripts Canada en veillant à l'intégrité des demandes de règlement pour soins de santé et en conservant un solide réseau de fournisseurs grâce à des examens diligents et à des conseils. Le vérificateur en soins dentaires est chargé d'effectuer différents types de vérifications partout au Canada afin de vérifier si les fournisseurs respectent les dispositions des régimes et les règles de pratique professionnelle. Le vérificateur utilise ses compétences en matière d'analyse et d'enquête ainsi que ses connaissances et son expérience en matière de couverture des soins de santé à l'échelle provinciale afin de déceler des tendances dans les demandes de règlement. Il s'assure également que les techniques de vérification évoluent afin de demeurer efficaces dans la gestion des risques auxquels les clients d'Express Scripts Canada sont exposés.

Responsabilités principales

Effectuer l'examen des demandes de règlement ainsi que des vérifications à distance et sur place.
Communiquer avec les fournisseurs pour obtenir des renseignements relatifs aux vérifications, les informer sur la manière de soumettre leurs demandes de règlement et répondre à leurs questions sur les résultats des vérifications.
S'assurer que les documents transmis par les fournisseurs respectent l'entente qu'ils ont conclue avec Express Scripts Canada, ainsi que les dispositions des régimes et les lois provincial