Description
The Extended Healthcare Claims Auditor role at Express Scripts Canada involves conducting audits across Canada to validate that providers are compliant with benefit plan design and professional practice regulations.
The Auditor uses analytical and investigative skills along with knowledge of provincial benefit coverage to identify trends and ensure audit techniques evolve to remain effective in managing risk.
Key Responsibilities:
- Perform claim verifications, desk and/or on-site audits
- Communicate with providers to gather information for audits, educate on claim submission practices, and respond to queries regarding audit results
- Assess provider documentation to ensure compliance with enrolment agreement, benefit plan design, and provincial regulations
- Calculate adjustments required to correct claim transactions
- Prepare, coordinate, and travel to conduct on-site audits at provider locations
- Compile and produce detailed and unbiased audit reports
- Perform self and peer-review to ensure accuracy and quality of claim reviews
- Track audit activity and summarize results for department statistics
- Identify trends and provide recommendations for risk criteria changes and/or candidates for audits
- Recommend ideas to increase ability to prevent and manage risk
- Respond to internal and external customer questions professionally and accurately
What We're Looking For:
- 2-5 years recent experience in a healthcare environment
- Graduate of an accredited pharmacy education program; RPhT designation is preferred
- Valid driver's license and ability to travel in Canada (20-30% of the time)
- In-depth knowledge of extended healthcare benefits and regulations is an asset
- Previous audit/investigation experience in the healthcare industry is an asset
- Experience with data and reports, with the ability to analyze information and identify inconsistencies
- Ability to manage confidential information and strong critical thinking skills
- Self-driven, curious, capable of working independently with minimal supervision
- Strong interpersonal skills and ability to work cross-functionally
- Flexible, resourceful, with a mindset that embraces change
- Ability to manage high priority tasks in a fast-paced environment
- Proficiency in MS Office (Excel, Word, Outlook)
- Bilingualism (French & English) is an asset
Why Join Us?
- Competitive compensation, benefits, and pension plan
- Career development and advancement opportunities
- A culture that celebrates innovation and collaboration
- Flexible work options and wellness programs