Role Responsibilities

Reporting to the Team Lead of the Provider Relationship and Claims Unit, the Practitioner Services Adjudicator will be responsible for the following responsibilities:

Adjudicates medical and allied claims that are being held for manual assessment for any of the assessment rule conditions related to the service provider or stakeholder: 

• Interprets the appropriate assessment of the claim, the Governing Rules, and provides appropriate information regarding the payment, refusal or adjustment of the claim.
• Accessing various internal systems, reviews rules, eligibility, rates, previous correspondence, Internet research and other related information.
• Referring to the 7 Schedules of Benefits, identifies procedure codes, price lists and governing rules that need to be accessed to adjudicate claims.
• Act as first level of appeal for Claims Processing/Corporate Support division claim assessment queries.
• Requests reports on questionable claims and practitioner/facility set up to detect over or under payments and inconsistencies in practitioner/facility information.

Registers service providers according to the licensing standards of the Primary and Preventative Health Services Ministry and their governing bodies: 

• Interprets licence types, skills and the restrictions applied to them according to the correspondence received from the CPSA. Decision making ability is required where limited precedents exist and a high degree of accuracy and understanding of the documents received is critical to ensure that the claims will pay according to the Schedule of Medical Benefits.
• Maintains the monthly changes and deletions listing with respect to the physician’s status with the CPSA to prevent inappropriate and or fraudulent billings.
• Creates business arrangements (BA) to determine the type of payment to be made. Ensures the accredited submitter associated with that BA is attached to prevent massive claim refusals.

Registers all Alternate Payment/Relationship Programs, the service providers and program/payment details:

• Reviews and determines from the agreement what needs to be maintained in the system to accommodate the funding model it represents; the terms of the contract, the sessional hours, and rates that are required for appropriate payment to the Regional Health Authorities, Physicians, ARP organizations and Professional Corporations.
• Ensures the contract and letters of participation are received, that all physicians identified in the contract have completed the letters and have correctly signed the documents for payments under them as physicians or professional corporations.
• Maintains or establishes each program according to the amended or renewed agreements on a yearly basis.
• Ensures the business arrangements are established correctly and the physicians are established to enable them to invoice directly with direct deposits to the bank accounts requested for each individual or organization. 

Role Responsibilities Cont.

Establishes facilities according to guidelines received from Ministerial orders and the CPSA:

• Establishes Sub Acute facilities to allow multilevel payments.
• Ensures each facility is established with the appropriate facility type and functional centres for the accurate billings of the service providers.
• Contacts hospitals and service providers when facilities no longer have the qualifications to provide specific services or have changed from one facility type to another.
• Impacts would be refusals of service provider claims, reciprocal refusals, improper reporting from Regional Health Authorities, more manual assessments of claims, inaccurate Morbidity and Ambulatory Abstract
• Reporting (MAACAR) and Management Information System (MIS) data, incorrect data for Records of Health Costs.
  

If you are ready to seize this exciting opportunity to make an impact within the Pharmaceutical and Supplementary Benefits division, please apply today, we would like to meet you!

Please click on this link to view the job description for this position.

APS Competencies

Competencies are behaviors that are essential to reach our goals in serving Albertans. We encourage you to have an in depth understanding of the competencies that are required for this opportunity and to be prepared to demonstrate them during the recruitment process.

This link will assist you with understanding competencies: https://www.alberta.ca/system/files/custom_downloaded_images/psc-alberta-public-service-competency-model.pdf.

• Agility: Proactively incorporates change into processes, creates opportunities for improvement Is aware of and adapts to changing priorities. Remains objective under pressure and supports others to manage their emotions, proactively explains impact of change on roles, and integrates change in existing work. Readily adapts plans and practices. 
• Drive for results: Works to remove barriers to outcomes, sticking to principles, forecasts and proactively addresses project challenges. Removes barriers to collaborate and achievement of outcomes. Upholds principles and confronts problems directly. Considers complex factors and aligns solutions with broader organization mission.
• Systems Thinking: Takes a long-term view towards organization's objectives and how to achieve them. Takes holistic long-term view of challenges and opportunities. Anticipates outcomes and potential impacts, seeks stakeholder perspectives. Works towards actions and plans aligned with APS values.
• Creative problem solving: Works in open teams to share ideas and process issues. Uses wide range of techniques to break down problems. Allows others to think creatively, voice ideas and brings the right people together to solve issues.
• Build collaborative environment: Involves a wide group of stakeholders when working on outcomes. Involves stakeholders, shares resources and positively resolves conflict through coaching and facilitated discussion. Uses enthusiasm to motivate and guide others. Acknowledges and works with diverse perspectives for achieving outcomes. 

Qualifications

Qualifications
High school diploma and four years of related experience.

Equivalency: Directly related experience or education considered on the basis of: one year of experience for one year of education or one year of education for one year of experience.

Knowledge:

• Experience in technical medical terminology or claims adjudication is an asset.
• Sound knowledge of the legislation, regulations, policies and procedures of the Primary and Preventative Health and an understanding of how these impact Practitioner and Facility Management.
• Familiarity with all the Regional Health Authorities and Accreditation of Health Facilities.
• Comprehensive knowledge of medical and dental terminology.
• Extensive and thorough knowledge of the Schedules of Medical Benefits and Allied Health Benefits, and the governing rules and regulations.
• Strong working knowledge of Ministry programs including Claims Assessment (CLASS), Stakeholder and Self Service Document Image Retrieval System (SSDIR).
• Strong working knowledge of MS Office (Word, Excel, Outlook and SharePoint).
  
  

Minimum recruitment standards outline the minimum education and experience required for appointment to a job classification. 
Refer to https://www.alberta.ca/alberta-public-service-minimum-recruitment-standards.

Notes

This competition will be used to staff (1) Full time Permanent position.

Hours of Work
7.25 hours daily/ 36.25 hours weekly, Monday to Friday
 
Location
ATB Place North, 10025 Jasper Avenue, Edmonton, Alberta.

Top candidates may be required to undergo security screening

A cover letter outlining how your experience relates to the qualifications of this role is required.

In your resume, please include dates (including months and years) associated with all education and work experience. Also, please indicate whether your work experience is casual, part time or full time.

Any costs associated with obtaining the required documents/checks as noted or interview travel expenses, will be the responsibility of the candidate. Out-of-province applicants can obtain the required documents/checks from the province they currently reside in.

Links and information on what the GoA has to offer to prospective employees.

• Working for the Alberta Public Service - https://www.alberta.ca/advantages-working-for-alberta-public-service.aspx.
• Public Service Pension Plan (PSPP) - https://www.pspp.ca.
• Alberta Public Service Benefit Information - https://www.alberta.ca/alberta-public-service-benefits.
• Professional learning and development - https://www.alberta.ca/professional-development-support-directive.
• Research Alberta Public Service Careers tool - https://researchapscareers.alberta.ca.
• Positive workplace culture and work-life balance.