Perform risk-based data profiling and analysis to identify trends and outliers in various categories for further review and investigation
Lead and support audit programs; coordinating, assessing, and making decisions on investigations
Take initiative and independently lead investigations to successful conclusion
Conduct interviews of plan members, providers of service and others as required
Create written audits and other correspondence to plan members, providers of service and others
Engage/interact/consult with various internal contacts such as Customer Service, Legal, Client Relations, Medical Consultants, Regional Group Office, and external stakeholders such as Health Practitioner Regulatory Bodies, Colleges and Associations, and Plan Sponsors
Lead, support and implement key investigative projects
Provide technical expertise to internal customers to troubleshoot claims payment, resolve escalated complaints, support issue trends etc.
Provide oversight of the drug audit program and risk assessment of claim initiatives and client customizations that relate to the drug benefit
Review and analyze high dollar drug claims and narcotics usage
Attend client meetings as required
Attend litigation/arbitration sessions in court if required
Requirements
Post-Secondary education or equivalent experience - pharmacy technician or pharmacy assistant background would be an asset
General understanding of medical terminology, diseases, and drug formularies
Good presentation and negotiation skills
Strong analytical, research, problem-solving and decision-making skills
Effective project management capabilities
Ability to review and analyze critical data to make formal recommendations for process improvements
Comfortable speaking with external parties such as pharmacists, health care providers, drug manufacturers, government agencies, plan members and plan sponsors etc.
Must be able to decipher health industry information and understand how it relates to Group Benefits' plans
Proven ability to manage/schedule a fluctuating, unpredictable and stressful workload
Knowledge of Group Benefits
Knowledge of the Canadian healthcare environment, service delivery model and regulation
Excellent understanding of third-party claims adjudication as it relates to Pharmacy benefits
Knowledge of fraud and abuse risk, and techniques to manage risk
Strong research, problem solving and decision-making skills
Ability to manage contentious interactions with various stakeholders
Excellent oral communication (both phone and face to face) and written communication
Intermediate data analysis skills with expertise using Excel and other data mining software
Demonstrate investigation skills with attention to detail
Knowledge of privacy, civil and criminal legal risks and processes
Benefits
health, dental, mental health, vision, short- and long-term disability, life and AD&D insurance coverage
adoption/surrogacy and wellness benefits
employee/family assistance plans
retirement savings plans (including pension and a global share ownership plan with employer matching contributions)
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