Dental Claims Auditor - Express Scripts

Job Title:

Dental Claims Auditor

Location:

Mississauga

Employment Type:

Permanent

Reason for Vacancy:  New Headcount

Work Arrangement:  Hybrid, 2 days a week on-site

Department Name:  Fraud, Waste, and Abuse

Pay Type:

Salary

Pay Range:  $58,000 – $63,000 annually

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 Us

Express 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 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.

Key Responsibilities

Perform claim verifications, desk and/or on-site audits for Dental, Vision, Mental Health and other healthcare benefits as needed
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 on-site audit at the provider’s 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

What We’re Looking For

Graduate of post-secondary educational program either as a dental assistant or dental hygienist with a valid license
2-5 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 20-30% of time
In-depth 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, 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…