Medical Claim jobs in Toronto, ON

WHY THIS ROLE MATTERS:

To conduct high quality and detailed Prescription Drug Claim Audits on behalf of our clients. This includes analyzing Prescription Drug claims data, detecting and evaluating patterns, trends and anomalies, and turning them into meaningful insights and recommendations for our clients through formal written reports and presentations.

A component of this role includes supporting our consulting team as a technical resource. Conducting technical reviews, insights, and recommendations for the Prescription Drug portion of our clients Group Benefits plans. Keeping up with key industry trends, new products, and processes is highly valued.

WHAT YOU’LL BE RESPONSIBLE FOR :

• Conduct high quality, detailed, Drug claim audits; evaluate adjudication processes, error rate, test plan eligibility and adherence to the insurance contracts
• Review, interpret, and summarize plan designs from insurance contracts
• Analyze drug claim data, and effectively detect and evaluate patterns, trends and anomalies
• Identify opportunities, solutions, and recommendations to improve claims administrative processes with a focus on cost savings and risk management
• Prepare written reports; technical writing outlining observations and findings of claim audits
• Participate in the preparation and presentation of audit insights, findings, and recommendations:
• to current or prospective clients; and
• to generate new business opportunities

WHAT YOU BRING TO THE ROLE:

• Demonstrated knowledge and experience of Group Benefits Prescription Drug plans, with experience in retail or hospital pharmacy, pharmacy operations, drug claim billing expertise, or insurance industry
• Five to ten years of experience in processing practices of drug claims for Group Benefit plans at a TPA, PBM and/or insurance company, and claims processing in a pharmacy setting
• Knowledge of Provincial Pharmacare Programs; including both private and public reimbursement models
• Solid background and familiarity with: Industry best practices, Coordination of benefits, Internal audit processes and fraud detection, Prescription Drug plan design, Drug Utilization Reviews, Drug pricing and fee structure, Brand and generic drugs, Narcotic controls.
• Strong communicator and presenter, able to manage multiple priorities in a fast-paced, fluctuating environment with strong written and verbal skills.
• Analytical and tech-proficient, with strong research, problem-solving, and decision-making skills, and proficiency in Word, Excel, and Outlook.

Assets

• Recent retail, commercial, or hospital pharmacy adjudication/processing experience is strongly preferred
• Experience in adjudicating Extended Health and prescription Drug claims at an insurer or TPA or PBM
• Experience with Pharmacy Benefits Management, drug plan design, or drug reimbursement models
• Experience in Group Benefits risk management, including fraud detection and prevention strategies

WHAT WE OFFER:

• Health and Dental Benefits
• RRSP Match Program
• Hybrid Work Environment
• Paid Vacation Time
• Educational Reimbursement
• Expense Reimbursement

This is for an existing position.

Navacord DOES NOT utilize artificial intelligence in the screening, assessment, or selection of applicants for this position.

Navacord is actively committed to support diversity, equity, and inclusion. We serve and recognize and respect human differences and similarities. We value the diversity of people and actively encourage women, indigenous peoples, members of visible minorities, people with disabilities, and lesbian, gay, bisexual, transgender, and queer (LGBTQ2+) persons to apply. We are committed to providing accommodation upon request for applicants and employees with disabilities. If you require accommodation, we will work with you to meet your needs.

Pay: $60,000.00-$80,000.00 per year

Benefits:

• Dental care
• Disability insurance
• Employee assistance program
• Extended health care
• Life insurance
• RRSP match
• Work from home

Work Location: Hybrid remote in Kleinburg, ON