Description
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We value our talented employees, and whenever possible strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think the open position you see is right for you, we encourage you to apply!
Our people make all the difference in our success.
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.
Location: Mississauga Head Office
Working Environment: Hybrid, 2 days/week on-site
ESSENTIAL FUNCTIONS:
Perform claim verifications financials, desk and/or on-site audits
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 ESC’s provider agreement, benefit plan design and provincial legislation
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 on-site 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
QUALIFICATIONS:
2-5 years recent experience in a health care environment
Must have a diploma from a recognized post-secondary educational program in the health services field
Valid driver’s license and ability to travel in Canada, range of 20-30% of the time
In-depth knowledge of extended healthcare benefits, reimbursement and extended health care regulations is an asset
Experience in report writing
Previous audit/investigation experience is an asset
Experience in data analysis, financial analysis and statistics
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 an asset
LOMA or HIAA training would be an asset
Note: Internal posting will be closed October 2, 2025.
Please note that you must meet our posting guidelines to be eligible for consideration. Policy can be reviewed at this link.
