Extended Healthcare Claims Auditor Express Scripts Canada
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Job Location:
Mississauga - Canada
Monthly Salary:
Not Disclosed
Posted on:
30+ days ago
Vacancies:
1 Vacancy
Job Summary
The role of the Fraud Waste & 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 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.
Location: Mississauga Head Office
Working Environment: Hybrid 2 days/week on-site
ESSENTIAL FUNCTIONS:
Perform claim verifications financials 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 ESCs 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 providers 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
QUALIFICATIONS:
2-5 years recent experience in a health care environment
Must have a diploma from a recognized post-secondary educational program in the health services field
Valid drivers license and ability to travel in Canada range of 20-30% of the time
In-depth knowledge of extended healthcare benefits reimbursement and extended health care regulations is an asset
Experience in report writing
Previous audit/investigation experience is an asset
Experience in data analysis financial analysis and statistics
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
Note: Internal posting will be closed October 2 2025.
Express Scripts Canada is a Cigna company
Express 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 Canada
Express Scripts Canada is a leading health benefits manager and has been recognized as one of the most innovative. Our clients include Canadas 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 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.
Key Skills
- Auditing
- Time Management
- ICD-10
- Accounting
- Component evaluation
- Workers' Compensation Law
- SOX
- Microsoft Excel
- CPT Coding
- Internal Audits
- Medicare
- Bookkeeping
About Company
Cigna Healthcare offers health insurance plans such as medical and dental to individuals and employers, international health insurance, and Medicare coverage.
