Medical Claims Adjudicator Level 1
Medical Claims Adjudicator Level 1
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Job Description
About PBC Solutions:
PBC Solutions has been recognized as one of British Columbias Top Employers for 2025!
PBC Solutions Ltd. was created in 2022 as a wholly owned subsidiary of PBC Health Benefits Society (operating as Pacific Blue Cross) #1 health benefits provider in BC. Our mandate is to design transform and deliver the benefits and claims administration services offered by governments and other large organizations along with our consortium partners DXC Advanced Solutions NTT DATA and EY.
Since the spring of 2023 PBC Solutions administers and leads the transformation and digitization of Health Insurance BC Services (HIBC) on behalf of the BC Ministry of Health. HIBC Services administers medicallynecessary insured doctor and hospital services through the Medical Services Plan (MSP) and drug coverage through the PharmaCare and Fair PharmaCare programs. In the future the business will expand to additional public and private client work.
Position Summary
Level 1 Medical Claims Adjudicators are adjudicators intraining for a Level 2 Medical Claims Adjudicator role and will progress to a Level 2 Medical Claims Adjudicator role. A Medical Claims Adjudicator Level 1 is in a formal training program for a period of up to one 1 full year. This role is supported by a Medical Claims Adjudicator Level 2 who possesses expertlevel knowledge and acts as a resource and subject matter expert to assist with applying and interpreting the various health acts and training of level 1 adjudicators.
The Medical Claims Adjudicator processes medical claims submitted for services from the general public practitioners and thirdparty insurers. This work involves reviewing all documentation in relation to a submitted claim so it requires a high level of privacy adherence accuracy and professionalism. Upon receiving the claims adjudicators assess several components to decide if the claim should be paid rejected or adjusted. For more complex claims the Medical Claims Adjudicator 1 shall seek assistance from Level 2 adjudicators as required.Decisions that adjudicators make adhere to several health acts and payment schedules.
This position is designated as a Grid 14 with an hourly range of $31.26 to $35.58. After 1 year of service the position becomes a Grid 18 which has an hourly range of $35.13 to $40.09.
Primary Duties
Adjudicate medical claims
- Validate information and documents provided by the general public practitioners and thirdparty payees.
- Apply MSC Payment Schedule or other Provincial Schedules (and ongoing fee updates) to determine if a claim should be rejected adjusted or paid as is then update the claim as appropriate
- Interpret and evaluate medical information photographs and reports
- Release (or not) personal information to thirdparty requesters
- May audit submitted claims to ensure billing integrity and accuracy
- Update Cheque Exception Lists and Reject Lists
- Correspond with general public practitioners and thirdparty payees to explain adjudication decisions or request additional information
- Consult with the medical and surgical advisors and consultants to resolve complex cases
- Adjust debit/credit amounts for practitioners
- Use a computer for extended periods of time
- Articulate client policies clearly neutrally and quickly
- Assist callers in the use of online forms and in submitting applications/documentation/claims
- Control calls (paraphrase actively listen empathize act)
- Update various IT and claims systems with validated customer or provider information
- Resolve escalations (transfers) from other departments
- Perform repetitive tasks and answer repetitive questions
- Comply to all regulations policies and procedures with minimal intervention
- Learn new policies procedures and computer applications within designated timelines
- Escalate work that is beyond the level they are assigned
- Obtain required approvals from designated personnel
- Document notes and actions in our systems that are clear objective and useful to others
- Utilize designated channels and systems for making recommendations communicating reporting etc.
- Report noncompliance of policies and procedures regardless of the cause
- Manage personal time with minimal impact to work time
- Track and update weekly/monthly schedule expectations as they are relayed
- Update your scheduler/supervisor with changes to your schedule as soon as you are aware of them and with consideration of our planning needs and the BCGEU Collective Agreement.
- Perform the work you are assigned within the designated time
- Report your time accurately in the appropriate system within deadlines
- Articulate concerns ideas and opinions in a professional manner
- Deescalate emotionally charged situations/calls
- Utilize prosocial skills (sharing taking turns manners negotiation problem solving smiling Impulse control interrupting/listening dealing with mistakes making decisions etc.
- Other duties as needed
- High school diploma or GED equivalent
- Intermediate level of MS Office Suite
- Required minimum of two years previous related experience in a customer serviceoriented administration position including dealing with customer inquiries over the phone and in person
- An equivalentcombination of education and experience may be considered.
- Preferred experience as a billing clerk in a medical setting
- Preferred experience in claims adjudication
- Preferred experience in the health sector
- Basic understanding of medical terminology
- Ability to effectively communicate both verbal and written
- Knowledge of principles related to privacy and security of personal information
- Demonstrated attention to detail
- Ability to operate standard office equipment
- Limited and growing knowledge of the MSC Payment Schedule and MSP claims procedures; required to analyze identify and apply the Canada Health Act Medicare Protection Act & Regulations and the Medical Services Commission Payment Schedule.
- Effective Communication
- Feedback
- Ensuring Accountability
- Problem Solving
- Multiple Demands and Time Management
- Customer Focus
- Decision Quality
- Teamwork
- Innovation
Whats in it for you
We offer a robust health & dental benefits plan with flexible options that will meet you and your familys needs. We also offer a Defined Benefit Pension Plan (PSPP) for all eligible employees as well as various generous paid leaves.
We strive to create a workplace where everyone feels valued and employees feel empowered to freely participate and contribute regardless of race ethnicity gender or gender identity sexual orientation religion ability education level parental status or socioeconomic status.
PBC Solutions is an equal opportunity employer and welcomes applications from all qualified candidates.
To request an accommodation in completing this application preemployment testing interviewing or otherwise participating in the employee selection process please direct your inquiries to
Does this opportunity resonate with you
Are you seeking a work environment that will challenge you provide stretch opportunities and support your success and growth Then youve found your ideal work environment Apply today please! Wed love to talk with you to explore this opportunity further with you.
Please note if selected for this opportunity you will be required to undergo a background check in accordance with PBC Solutions policies.
We sincerely thank all candidates for their interest however only those selected to continue in the recruitment process will be contacted.
Please apply by April 11 2025 by 4:00 PM PST. An eligibility list may be established for this position.
How we work
Our Guiding Principles
Honesty We will be truthful. We will create a safe environment to communicate proactively openly and with respect. We will be transparent and genuine with our interests.
Integrity We will act consistently to do the right thing and ensure our words and actions align. Embracing opportunities and challenges we will live our shared values and vision.
Reciprocity We will strive for fair and balanced exchanges leveraging our unique strengths and resources recognizing this requires an ongoing give and take. We will win and lose as one.
Autonomy We respect and acknowledge the interests of each party. We trust each other to make decisions and act based on our diverse strengths to achieve our mutually desired outcomes.
Loyalty We will be bold brave and committed to our relationship. As partners we will advocate for one another celebrate our successes and have each others back through our challenges.
Equity We commit to a balanced partnership. We will make decisions and act based on a fair assessment of capabilities risks constraints and opportunities to achieve mutual success.
Our Intended Behaviours
Communication We actively communicate in a timely open respectful and responsive manner with the intent to gain understanding and find solutions.
Flexibility We will be agile adaptable and creative to enable responsive service delivery and embrace challenges and change with an openminded and positive attitude.
Perspective We seek to understand interests assumptions actions and diverse backgrounds by actively sharing and exploring all points of view.
Focus We will use our Shared Vision as our North Star to evaluate prioritize and deliver successful results.
Trust & Confidence We lead with trust. We consistently behave in ways that earn and inspire confidence by being credible reliable and transparent even when vulnerable.
Feedback No surprises. We will maintain a strong relationship through timely purposeful feedback in a safe respectful and collaborative environment.
Solutionoriented We see possibilities rather than limitations. We use our diverse capabilities to develop options to resolve our challenges.
Employment Type
Full Time
