Pharmacy Claims Auditor – 12‑Month Contract

About the role

The Business Integrity team at Express Scripts Canada seeks a Pharmacy Claims Auditor to protect the integrity of health claims across Canada. You will conduct desk and on‑site audits, verify claim compliance with benefit plan designs and provincial regulations, and collaborate with providers to improve claim submission practices.

Key responsibilities

• Perform claim verifications, desk and/or on‑site audits.
• Communicate with providers to gather information, educate on claim submission practices, and respond to audit queries.
• Assess provider documentation for compliance with ESC’s provider agreement, benefit plan design, and provincial legislation.
• Calculate adjustments required to correct claim transactions.
• Prepare, coordinate, and travel to conduct on‑site audits, completing post‑audit activities.
• Compile detailed, unbiased audit reports.
• Conduct self and peer reviews to ensure accuracy and quality of claim reviews.
• Track audit activity, summarize daily/monthly results, and present statistics to customers.
• Identify trends, recommend risk criteria changes, and suggest candidates for future audits.
• Propose incremental ideas to prevent and manage risk, adding value for customers.

Required profile

• Strong analytical and investigative abilities.
• Knowledge of provincial pharmacy benefit coverage and related legislation.
• Experience reviewing provider documentation and calculating claim adjustments.
• Effective communication skills for interacting with providers and internal stakeholders.

Required skills

What we offer

• Hourly rate $30.75‑$33.00 (CAD) based on experience.
• Hybrid work arrangement with travel to provider sites as needed.
• 12‑month contract with potential for extension.