Claims Investigator (Pharmacy, Dental, EHC)

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Claims Investigator (Pharmacy, Dental, EHC)

Job Information
Author pmnationtalk
Date June 21, 2019
Type Full Time
Company Express Scripts Canada
Location Mississauga, ON
Category Medical / Health
Client Express Scripts Canada
Contact Information
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Claims Investigator (Pharmacy, Dental, EHC)

Reporting to the Audit Program Manager, the incumbent will be responsible identifying and investigating pharmacy, dental and EHC providers, plan members, and prescribers for fraud, waste, and abuse risks associated to ESC’s clients. Using critical thinking skills and data analytics, the incumbent will complete complex investigational audits reviews in order to correct risks identified and protecting client’s health benefit plans assets, and present findings both verbally and in writing to key internal and external stakeholders.  In addition, the Claims Investigator will participate in  identifying and recommending policy, and procedures, and systems changes to enhance case development efficiency and quality of cases.

Key Responsibilities:

  • Analyze and evaluate potential fraud and abuse situations using corroboratory information obtained by correspondence with members, physicians, and pharmacies.
  • Identify and investigate cases of suspected fraud and high abuse for assigned clients.Develop these cases in compliance with any applicable policies, procedures, or regulatory requirements.
  • Prepare formal and thorough written reports to upper management, and clients, expressing the findings of completed investigations.
  • Prepare for and take lead role in client communications, including conference calls and on-site meetings, to present status updates of ongoing issues, results of completed investigations, etc., for assigned clients.
  • Identify and perform special projects.
  • Manage Fraud tips (through from emails, fraud tip line, client referrals, etc). Track and monitor status of each investigation.


  • Bachelor’s degree or equivalent work experience
  • 2-5 years of relevant experience as a pharmacy technician, health care professional, or data analyst
  • Certified Pharmacy Technician, Certified Fraud Examiner, or similar certification strongly desired
  • Highly proficient in Microsoft Access & Excel, and data warehousing applications.Excellent organizational and interpersonal skills, critical thinking and planning skills, verbal and written communication skills, including ability to present to clients and internal stakeholders
  • Ability to work well with senior management and high level external contacts, handle sensitive or confidential information is critical, work with minimum management oversight on multiple projects with competing priorities, Ability to work a flexible schedule to accommodate project deadlines


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, 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


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