The goal of the Business Integrity team is to evolve capabilities that effectively detect and address the fraud, waste and abuse of claims submitted on behalf of ESC customers. This role will focus on enhancing the Express Scripts Canada (ESC) value proposition for customers to ensure the integrity of health claims and benefit plans while maintaining a network of providers through diligent review, education and recovery of unsubstantiated funds. As a thought leader, the Audit Program Advisor will provide on-going professional guidance and recommendations that improve our capabilities to detect fraud, waste and abuse as well as providing education to service providers for all benefit types (pharmacy, extended health care services and dental). This role will work closely with data analysts, reporting specialists, investigators and auditors to ensure the governance and accuracy of audit application and service delivery. The candidate will work closely with the audit leadership team to assist with the development of the audit program to ensure that the program remains current with the changing pharmacy landscape and extended scope of practice.
Recommend and help to prioritize potential provider audits based upon risk analysis of billed claims
Review audit reports for quality, accuracy, and proper audit application
Support auditors in responding to provider inquires, legal inquires and escalations
Continuously review and provide recommendations regarding claims verification risk criteria to ensure ESC is proactively identifying known industry risks for customers
Works with data analysts to analyze claims data and drug trends to forecast areas of program risk
Collaborate with leadership to review audit program to maximize program potential
Deliver evidence-based research to support discussions and decisions
Provide guidance and oversight to audit specialists
Review provider claims reports to identify abnormal or inconsistent claims submissions
Participate as required in peer reviews with external clients and provide support to audit specialists
Consult with internal and external stakeholders regarding audit activities
Support audit team in customer facing meetings
Additional duties as assigned by leadership
Recommend incremental and continuous ideas that will increase ability to prevent and manage risk that will bring the most value to customers
Bachelor of Science-Pharmacy or PharmD
Valid pharmacist licensure to practice pharmacy in Canada required
5+ years of experience in a hospital, community pharmacy setting, or experience in group benefits including pharmacy benefits
Knowledge of provincial and federal pharmacy regulations and legislative requirements
Demonstrated interpersonal skills to facilitate change management
team player and ability to work cross-functionally with other departments
Excellent time and resource management skills
Self-driven, curious, ability to work independently with minimal supervision
Proven ability to manage competing priorities in a fast based environment
Strong focus on quality and accuracy
Detail-oriented with proven high-level oral and written communication skills
Demonstrates and applies integrity in all aspects of work
Knowledge of Microsoft Office software (Word, Excel and PowerPoint)
About Express Scripts Canada
Express Scripts Canada, a registered business name of ESI Canada, an Ontario partnership indirectly controlled by Express Scripts, Inc. (Nasdaq: ESRX), is one of Canada’s leading providers of health benefits management services. From its corporate headquarters in Mississauga, Ontario, just outside Toronto, Express Scripts Canada provides a full range of integrated pharmacy benefit management (PBM) services to insurers, third-party administrators, plan sponsors and the public sector, including health-claims adjudication and processing services, Home Delivery Pharmacy Services, benefit-design consultation, drug-utilization review, formulary management, and medical and drug-data analysis services, to better facilitate the best possible health outcomes at the lowest possible cost.
It will be a condition of employment that the successful candidate receives the Enhanced Reliability Clearance from the Federal Government. The candidate will be required to provide supporting documentation in order 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.
Thank you for your interest in this position however, only qualified candidates will be contacted for an interview. No telephone calls please.
For more information about Express Scripts Canada, visit its Web site at www.express-scripts.ca
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