Extended Health Care Claims Auditor - Express Scripts Canada

Job Title: Extended Healthcare Claims AuditorLocation: MississaugaEmployment Type:  ContractReason for Vacancy: New HeadcountWork Arrangement: HybridDepartment Name: Fraud, Waste, and AbusePay Type: HourlyPay Range: $30.75 to $33.00. Please note that this is a general posting range and offer range will be varied based on relevant experience, qualifications, skills required and location for this role.About UsExpress Scripts Canada (ESC) is a leading health benefits management company. Serving over 12 million members, we help insurance carriers, third party administrators, and the public sector optimize the value of health benefits by linking the talent and professional expertise of our people with leading edge information management systems and technology. ESC is a wholly owned subsidiary of Express Scripts Inc., one of the largest pharmacy benefit management (PBM) companies in North America, part of The Cigna Group (NYSE: CI), a global health company. Together, we deliver innovative, cost-effective solutions that improve access, affordability, and health outcomes for Canadians.Job Summary:The role of the Business Integrity 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.This role is particularly well-suited for individuals with a background as a Pharmacy Assistant or Pharmacy Technician who are looking to leverage their clinical knowledge in a dynamic, insight-driven role.Key Responsibilities:Perform claim verifications, desk and/or on-site auditsCommunicate with providers to gather information for audits, to educate on claim submission practices and to respond to queries in regards to audit resultsAssess provider documentation to ensure compliance with enrolment agreement, benefit plan design and provincial regulations.Calculate the adjustments required to correct claim transactionsPrepare, coordinate and travel to conduct on-site audit at the provider’s location, and complete the post on-site audit activitiesCompile and produce audit reports that are detailed and unbiasedPerform self and peer-review to ensure accuracy and quality of claim reviewsTrack audit activity and summarize results of claim analysis and recoveries on a daily and/or monthly basis for department statistics for presentation to customersIdentify 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 customersRespond to internal and external customer questions professionally, timely and accuratelyOther duties and responsibilities as assignedWhat We’re Looking For2-5 years recent experience in a health care environmentGraduate of an accredited pharmacy education program; RPhT. designation is preferredValid driver’s license and ability to travel in Canada, range of 20-30% of the timeIn-depth knowledge of extended healthcare benefits, reimbursement and extended health care regulations is an assetPrevious audit/investigation experience in the healthcare industry is an assetExperience with working with data and reports, with the ability to analyze information and identify inconsistencies.Ability to manage confidential informationEffective time management and organizational skillsStrong critical thinking skills with ability to analyze, problem-solve and mediate difficult situationsSelf-driven, curious, capable of working independently with minimal supervisionStrong interpersonal skills: team player and ability to work cross-functionally with other departmentsFlexible, resourceful, with a mindset that embraces and champions changeAbility to manage high priority tasks in a fast-paced environmentAbility to research and effectively communicate findingsPassionate about development and continuous learningExcellent verbal and written communication skillsProficiency in MS Office (Excel, Word, Outlook)Bilingualism (French & English) is an assetLOMA or HIAA training would be an assetWhy Join Us?Competitive compensation, benefits and pension planCareer development and advancement opportunitiesA culture that celebrates innovation and collaborationFlexible work options and wellness programsPre-Employment RequirementsAll offers of employment are conditional upon the successful completion of reference checks and background verification in accordance with company policy. Within ESC, for certain positions, obtaining and maintaining a federal government security clearance is a condition of employment. Candidates applying for such roles must meet all eligibility criteria for the applicable clearance level and consent to the security screening process as mandated by federal regulations. Failure to obtain or maintain the required clearance will result in withdrawal of the offer or termination of employment.Our hiring process includes AI-powered tools to conduct video interviews, take notes and score candidates; however, all scores will be reviewed by hiring managers and our Talent team before making a decision.NOTE: Internal posting will be closed on June 29, 2026.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 offe