Pharmacy Claims Investigator

Pharmacy Claims Investigator

Job Information
Author pmnationtalk
Date September 17, 2021
Deadline Open
Type Full Time
Company Express Scripts Canada
Location Mississauga, ON
Category Pharmacist
Client Express Scripts Canada
Contact Information
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Pharmacy Claims Investigator

The objective of the Pharmacy Audit Services team is to proactively detect and address risks in a timely manner that effectively manages the financial risk and reputation of Express Scripts Canada customers. The Investigator is responsible for conducting audits and investigation, which will help detect fraud, waste, and abuse in claim submissions and prevent future misuse. This is achieved by identifying provider, member and prescriber fraud and abuse risks using expertise, knowledge, data analytics, and critical thinking skills to take a proactive risk management approach.  The investigator is responsible for conducting complex investigational audits and present findings both verbally and in writing to key internal and external stakeholders, including coordinating and providing updates to customers risk management team(s) as necessary.  The investigator also serves as a lead in developing and mentoring the Auditors on the team.


  • 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. Document all information collected in an organized and timely manner. Track and monitor status of each investigation.
  • Prepare for and take lead role as the subject matter expert 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 and program initiatives.
  • Work with both internal and external stakeholders to address client inquiries, gather, collect information, and coordinate investigations.
  • Provide testimonies for legal proceedings.
  • Manage fraud tips (through emails, fraud tip line, client referrals, etc.).
  • Continuously seek opportunities to create efficiencies within processes and drive value for the program.
  • Assist in mentoring and developing team members.


  • Bachelor’s degree or equivalent work experience
  • 2-5 years of relevant experience as a pharmacy technician, health care professional, or data analyst
  • Registered Pharmacy Technician, Certified Fraud Examiner, or similar certification strongly desired
  • Knowledge of healthcare laws, rules, and regulations across the country; clear understanding of investigation techniques and methods.
  • Highly proficient in Microsoft Access & Excel, and data warehousing applications.
  • Display high levels of curiosity, integrity, tact and objective judgement
  • Excellent organizational, planning and critical thinking skills
  • Excellent verbal and written communication skills, including ability to present to clients and internal stakeholders
  • Proven interpersonal skills and ability to work well with senior management and high-level external contacts handling sensitive or confidential information is critical
  • Ability to work with minimum management oversight on multiple projects with competing priorities; Ability to work a flexible schedule in high pressure environments with urgent deadlines.
  • Demonstrated adaptability, self-motivation and resiliency

Deadline for internal applicants to apply  is October 1, 2021.

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 offers an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioural health, pharmacy, vision, supplemental benefits, and other related products.

About Express Scripts Canada

Express Scripts Canada is a leading health benefits manager and has been recognized as one of the most innovative. Our clients include Canada’s leading insurers, third party administrators and governments. We work with these clients to develop industry-leading solutions to deliver superior healthcare in a cost-controlled environment. We provide Active Pharmacy™ services to more than 7 million Canadian patients and adjudicate more than 100 million pharmacy, dental, and extended health claims annually. Through our proprietary consumer intelligence, clinical expertise, and patients-first approach, we promote better health decisions for plan members, while managing and reducing drug benefit costs for plan sponsors.

It will be a condition of employment that the successful candidate obtains an Enhanced Reliability Clearance from the Federal Government. The candidate will be required to provide supporting documentation to receive clearance if required.

We offer a competitive salary and benefits package, 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.

If you require accommodation in completing the online application process, please email: [email protected] Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.

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