Claims Auditor (Pharmacy) – Claims Audit & Investigation Services

ABC Benefits Corporation; Alberta; On-site; CAD 65,000 - 90,000; Full time

Job summary

Alberta Blue Cross is seeking a claims audit and investigations professional to develop and execute audit plans, collect documentation, and prepare formal reports. The role emphasizes field work, travel within Alberta, and ensuring compliance with provider agreements and legislation.

Ideal candidates will have investigative interviewing experience, strong communication skills, and the ability to analyze large datasets with Excel.

Qualifications

• Post‑secondary education in science or business, criminal justice, health care and/or law.
• Investigation interviewing experience is an asset.
• Strong written and verbal communication; ability to analyze large data sets in Excel.
• Ability to work independently in a virtual team with accountability.

Responsibilities

• Conduct pharmacy and health audits/investigations and prepare reports.
• Travel within Alberta; collect documentation and perform field work.
• Analyze claims to ensure compliance with agreements, policies and laws.
• Develop working papers and issue reports on claims and monetary adjustments.

Skills

Analytical thinking

Communication skills

Interviewing

Data analysis (Excel)

Independent work

Education

Post-secondary education in science or business, criminal justice, health care and/or law

Tools

Excel

Databases

Job description

Alberta Blue Cross® is an Alberta based organization dedicated to delivering exceptional customer experience and community leadership. We’re committed to providing the best health coverage to over 1.8 million members and take an active role in promoting wellness. We believe in what we do—and place trust in our employees to deliver our vision. Working at Alberta Blue Cross® means having a career where you’ll be recognized for your contributions. We value diversity, encourage our team members to maintain a healthy work-life balance and provide opportunities for career growth.

OVERVIEW

Claims Audit and Investigation Services conducts audits and investigations of dental and health care providers and plan members to assure compliance with provider agreements, group contract, policies procedures, and applicable legislation. The Audit and Investigations teams’ main responsibility is to identify and investigate fraud and /or non-compliance to relevant billing agreements, and report on the investigation findings related to dental and health benefits claims. Working in a mobile work style arrangement within a team environment, this position will be responsible for developing an audit investigation plan, executing the audit, and creating the final report. You must have experience with interviewing and investigation, excellent written and verbal communication skills, strong analytical and problem-solving ability, and outstanding commitment to providing excellent service.

WHAT YOU WILL DO

Conduct pharmacy and/or health audits/investigations and ensure investigation and reporting meet all required standards. Field work to collect documentation is a key aspect of this role. Travel is required within Alberta (A valid Class 5 Driver's License is required) Complete claims analysis to assure compliance with provider agreements, group contracts, policies, procedures, applicable legislation. Prepare working papers, letters, and reports. Issue reports on claims and /or monetary adjustments and changes in practice to facilitate compliance. Develop and maintain good relationships with service providers and internal partners. Proactively address internal and external clients’ needs that are escalated to you and help to prioritize work items to meet client service standards. Recommend changes to processes, policies, and procedures to optimize service delivery and enhance productivity.

WHAT YOU WILL HAVE

Post‑secondary education in science or business, criminal justice, health care and/or law. An investigative designation such as CFI, or CFE is preferrable. Exceptional communication skills, including written and verbal. Experience in investigation interviewing is an asset. Commitment to quality customer service is required for success in this position. This includes the ability to establish and maintain effective working relationships with both internal and external customers. Knowledge of databases and ability to analyze large amounts of data using Microsoft excel. Ability to work well independently as part of a virtual team, with a strong sense of responsibility and accountability. Experience in the dental and health care benefits industry such as registered pharmacy assistant, pharmacy technician or other related health discipline is preferrable.

This position will remain open until a suitable candidate is selected. Alberta Blue Cross® is an inclusive employer committed to a workplace that reflects the diversity of the communities we serve. We empower and are advocates for our team members by welcoming, respecting and valuing their unique perspectives, backgrounds, and experiences. We offer the opportunity to work in an innovative, high-energy team-focused environment. A criminal record check satisfactory to Alberta Blue Cross will be required as a condition of employment, following a conditional offer.

Alberta Blue Cross® is an Alberta based not‑for‑profit, dedicated to delivering exceptional customer experience and community leadership. We are committed to providing the best health coverage to over 1.8 million members and take an active role in promoting the wellness of all Albertans. We believe in what we do—and place trust in our employees to deliver our vision. Privacy Policy Terms of Use ®* The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ®† Blue Shield is a registered trade‑mark of the Blue Cross Blue Shield Association.