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Location: Mississauga or Montreal
Employment Type: Permanent

Reason for Vacancy: Replacement

Work Arrangement: Hybrid

Department Name: Fraud, Waste, and Abuse

Pay Range: $58,000 – $65,000

Please note that this is a general posting range and offer range will be varied based on relevant experience, qualifications, skills required and location for this role.

About Us

Job Summary

The role of the Fraud, Waste & Abuse team is to enhance the Express Scripts Canada (ESC) value proposition for customers to ensure the integrity of health claims while maintaining a network of providers through diligent review and education. The Auditor is responsible to conduct various types of audits across Canada to validate that providers are compliant with benefit plan design and professional practice regulations. The Auditor uses their analytical and investigative skills along with their practice and knowledge of provincial benefit coverage to identify trends observed from claim reviews and to ensure that the audit techniques evolve to remain effective in managing 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, to educate on claim submission practices and to respond to queries in regards to audit results




- 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 the 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 for department statistics for presentation to customers
- Identify trends observed from claim reviews and provide recommendations for risk criteria changes and/or candidates for a desk or in office audit.
- Recommend incremental and continuous ideas that will increase ability to prevent and manage risk that will bring the most value to customers
- 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 either 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 with other departments
- Flexible, resourceful, with a mindset that embraces and champions change
- Ability to manage high priority tasks in a fast-paced environment
- Ability to research and effectively communicate findings
- Passionate about development and continuous learning
- Excellent verbal and written communication skills
- Proficiency in MS Office (Excel, Word, Outlook)
- Bilingualism (French & English) is a requirement
- LOMA or HIAA training would be 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 the successful completion of reference checks and background verification in accordance with company policy. Within ESC, for certain positions, obtaining and maintaining a federal government

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