Dental Claims Auditor - 12 Month Contract - Express Scripts Canada
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Key skills for this role
About the Role
Express Scripts Canada is seeking a Dental Claims Auditor for a 12-month contract to join the Fraud, Waste, and Abuse team. The role involves conducting audits of dental and other healthcare claims, ensuring compliance with benefit plan design and regulations.
Key Skills for This Role
Responsibilities
- Perform claim verifications, desk and/or on site audits for Dental, Vision, Mental Health and other healthcare benefits
- Communicate with providers to gather information for audits, educate on claim submission practices, and respond to queries
- Assess provider documentation for compliance with enrolment agreement, benefit plan design and provincial regulations
- Calculate adjustments required to correct claim transactions
- Prepare, coordinate and travel to conduct on site audits at provider locations
- Compile and produce detailed, unbiased audit reports
- Perform self and peer review to ensure accuracy and quality of claim reviews
- Track audit activity and summarize results for department statistics
- Identify trends from claim reviews and recommend risk criteria changes
- Respond to internal and external customer questions professionally and accurately
Requirements
- Graduate of post secondary dental assistant or dental hygienist program with valid license
- 2 5 years recent experience in a dental office environment with knowledge of dental software and fee codes
- Valid driver's license and ability to travel in Canada (20 30% of time)
- In depth knowledge of dental benefits, reimbursement and dental regulations
- Proficiency in MS Office (Excel, Word, Outlook)
- Excellent verbal and written communication skills
- Previous audit/investigation experience is an asset
- Bilingualism (French English) is an asset
- LOMA or HIAA training would be an asset
Full Job Posting
Job Summary
- The Fraud, Waste Abuse team enhances the ESC value proposition by ensuring health claims integrity through diligent review and education.
- The Auditor conducts various audits across Canada to validate provider compliance with benefit plan design and professional practice regulations.
- The Auditor uses analytical and investigative skills to identify trends and ensure audit techniques evolve to manage 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, educate on claim submission practices and respond to queries.
- 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 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.
- Identify trends observed from claim reviews and provide recommendations for risk criteria changes.
- Recommend incremental and continuous ideas to increase ability to prevent and manage risk.
- 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 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.
- Flexible, resourceful, with a mindset that embraces and champions change.
- Excellent verbal and written communication skills; proficiency in MS Office; bilingualism (French English) is an asset.
Why Join Us
- Competitive compensation, benefits and pension plan.
- Career development and advancement opportunities.
- A culture that celebrates innovation and collaboration.
- Flexible work options and wellness programs.
Pre Employment Requirements
- All offers of employment are conditional upon successful completion of reference checks and background verification.
- Obtaining and maintaining a federal government security clearance is a condition of employment for certain positions.
- Our hiring process includes AI powered tools for video interviews and note taking; all scores are reviewed by hiring managers.
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