Specialist, eClaims

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At Ontario Health we are committed to developing a strong organizational culture that connects and inspires all team members across the province. Our vision is that together we will be a leader in health and wellness for all. Our mission is to connect the health system to drive improved and equitable health outcomes experiences and value. How we work together is reflected through our five values: integrity inspiration tenacity humility and care.

What Ontario Health offers:

At Ontario Health your growth and well-being arent just supportedtheyre celebrated every step of the way. Here you have the opportunity to make a meaningful impact while shaping a fulfilling and sustainable career. Based on your role you may receive:

• Comprehensive health coverage from day one with fully paid medical dental and vision benefits to support you and your familys health
• Flexible health care or wellness spending accounts plus an inclusive program to support your overall well-being
• A premium defined benefit pension plan ensuring long-term financial security
• Competitive vacation entitlement that encourages time to rest and recharge
• Three personal days and two float days annually providing added flexibility to support work-life balance in addition to vacation days
• Ongoing learning and career development opportunities designed to help you grow advance and thrive in your profession
• A collaborative values-driven workplace where integrity care humility inspiration and tenacity shape everything we do
• Opportunities to participate in Communities of Inclusion fostering belonging equity and the sharing of diverse perspectives across our team

Want to make a difference in your career Consider this opportunity.

The Provincial Drug Reimbursement Programs (PDRP) unit at Ontario Health plays a critical role in helping patients across Ontario access high-cost cancer drugs and specialized services. On behalf of and in support of the Ministry of Health PDRP administers adjudication and funding programs that assess the clinical and cost-effectiveness of new and emerging therapies and supports equitable transparent access for eligible patients.

PDRP administers key provincial programs including the New Drug Funding Program High Cost Therapy Funding Program Evidence-Building Program and Case-by-Case Review Program. The team also supports Ontario Healths Out-of-Country programs adjudicates funding requests for CAR T-cell therapy delivers an Evidence Search and Review Service and supports the Ontario Health Infectious Diseases Advisory Committee.

The Specialist is responsible for the day-to-day operations of PDRPs population-based funding programs (NDFP EBP HCTFP) ensuring that patients have access to treatments without delay and are the primary points of contact for our partners in close to 80 Ontario hospitals and cancer centres. The Specialist will develop enrolment forms and business rules to support the adjudication of patient eligibility assessment and treatment claims for provincially funded cancer drugs using an electronic claims adjudication application (eClaims) and a business rule authoring software (InRule irAuthor). The Specialist supports the Managers Pharmacists and other program staff in delivering on the mandates of the programs within specific areas of expertise by executing key activities and developing the required deliverables. The Specialist supports the development of the required policies (including implementation of new therapies) processes tools and technology to implement these key activities and deliver on program operations and initiatives.

The Specialist supports programs that are large and broad in scope and are related to more than one focused area of expertise. The work associated with the position impacts the success of the program and the overall business unit based on the accomplishment of key responsibilities and activities within areas of expertise.

The Specialist regularly liaises with staff throughout Ontario Health (other clinical programs Legal and Privacy Office Finance Communications Information Technology and Analytics). They may also engage with clinicians hospital administrators the ministry and other key stakeholders across the province.

Here is what you will be doing:

Program / operational support

• Develop and maintain operational policies and processes for the timely review and adjudication of individual patient applications for high-cost therapies.

• Refine tools that leverage best use of technology and enable highly efficient program operations.

• Implement new cancer drug funding policies into the programs adjudication and reimbursement application including developing enrolment forms and adjudication rules to assess eligibility of enrolments and claims (using eClaims and InRules irAuthor platform).

• Interpret and apply clinical criteria to verify eligibility of individual patient requests using clinical expert reviewer and pharmacist input as required.

• Adjudicate enrolments and treatments for high-cost therapies to align with accounting best practice and payment of monthly invoices in a timely manner.

• Work collaboratively with internal team members (clinical and technical staff) clinical expert reviewers and the ministry to support the timely implementation of new drug funding policies.

• Support a measurement plan and evaluation framework to monitor program operations that will enable operational excellence in program delivery. Analyze quantitative and qualitative data and prepare reports and presentations as required.

• Identify technical needs provide input into business requirements and work with colleagues to develop and test enhancements on electronic tools.

• Work with clinical experts and other clinical program staff to create revise and clarify eligibility criteria on high-cost therapies.

• Support prepare materials for and present at meetings conferences working groups advisory committees and steering committees as required.

• Perform cross-functional tasks and other duties as required.

Communications stakeholder management issues management

• Clearly communicate funding decisions and rationale to clinicians/hospital staff.

• Interpret reimbursement policies and clarify eligibility criteria with stakeholders. Provide clear consistent accurate and timely written communication concerning reimbursement decisions and policies.

• Develop and foster effective working relationships with internal and external stakeholders including health care providers administrators the ministry other program teams and committees.

• Liaise with internal staff and management Ontario Health Communications and the ministry on urgent or contentious inquiries by providing subject matter expertise (SME) in the development of responses and key messages as required.

• Identify and escalate risks to Pharmacists other clinical SMEs and Manager and propose recommendations to address the issues identified.

• Develop various products to support internal and external communications reporting and decision-making including memos briefing notes reports status updates presentations and other documents as required.

• Develop and present materials using excellent written verbal and graphical communications skills as required.

• Provide support and coordinate meetings for internal and external groups including organizing meeting logistics preparing meeting materials tracking action items and ensuring appropriate follow up as required.

• Maintain documentation and modify and/or suggest improvements as required.

Here is what you will need to be successful:

Education and Experience

• An undergraduate degree in Health Studies Health Systems Health Services Research Public Health Information Management Health Informatics Health Administration or equivalent combination of education and experience.

• 3 years of related experience in a health care setting government or agency or other organization in the health sector.

• Experience reviewing and understanding medical records and being able to apply eligibility criteria to individual cases.

• A strong understanding of the Ontario health care landscape specifically in oncology.

• Experience with eClaims Ontario Healths web-based claims adjudication and reimbursement system and InRule irAuthor is an asset.

• Experience working with health care providers and administrators.

• Knowledge of public healthcare systems and policies particularly the Ontario drug reimbursement system is an asset.

Knowledge and Skills

• Ability to translate clinical use cases into a business logic algorithms.

• Excellent interpersonal and stakeholder management skills. Demonstrated ability to build relationships with colleagues clinicians and other stakeholders and defuse issues or conflicts that may arise.

• Excellent oral and written communication skills including the ability to clearly and concisely articulate key messages that resonate with different stakeholders and audiences.

• Superior attention to detail organization and time management skills with ability to prioritize and manage several tasks.

• Strong critical and analytical thinking and problem-solving skills.

• Takes initiative and can work independently using sound judgment.

• Works collaboratively with others supporting the needs and goals of the team including taking on stretch assignments and/or providing coverage for colleagues.

• Demonstrated confidence in making decisions seeking input when required.

• Demonstrated history of using discretion in dealing with sensitive issues and maintaining appropriate levels of confidentiality.

• Ability to define problems find solutions and provide well-articulated recommendations.

• Ability to ensure completed work outputs meet key program objectives and adhere to standards protocols and guidelines.

• Experience with Microsoft Office tools including Outlook PowerPoint Excel (advanced formulas) and Word is required.

• Experience with data manipulation languages (e.g. SQL queries) is an asset.

• Demonstrated commitment to lifelong learning and continuous professional development.

• Highly productive and motivated capable of quality output and able to multitask and prioritize to meet timelines and manage competing priorities.

• Creative and forward thinking with a desire to learn and take on new opportunities.

• Self-directed with enthusiasm initiative and demonstrated ability to work independently and collaboratively to achieve deadlines and high-quality deliverables.

• Ability to work well under pressure in a fast-paced environment and exercise high caliber judgment.

• Comfortable working in a dynamic fast-paced environment with a degree of uncertainty or ambiguity.

• Must be team-oriented possess a positive attitude and be committed to organizational health culture and values.

Location: Ontario Health (OH) welcomes applications from candidates across Ontario. Please note that this role follows an in-office work model requiring employees to work from a designated approved Ontario Health location.

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