City : Burnaby

Category : Health Insurance

Industry : Insurance

Employer : Pacific Blue Cross

Pacific Blue Cross has been British Columbia's leading benefits provider for 80 years. We are an independent, not-for-profit society with strong roots in BC’s health care system. Together with our subsidiary BC Life, we provide health, dental, life, disability and travel coverage to 1 in 3 British Columbians through employee group plans and individual plans.

We are fueled by a commitment to keep health care sustainable for all British Columbians. Through our Pacific Blue Cross Health Foundation, we also provide funding to community organizations with a focus on alleviating mental illness and chronic disease. We're interested in finding people who want to make a difference and who will take advantage of every opportunity to build a career with us.

Pacific Blue Cross offers an attractive compensation and benefits package, fitness programs, and an onsite gym and cafeteria. Our workplace culture values health and wellness, continuing education, environmental sustainability and giving back to the community.

If you are committed to improving the health and well-being of British Columbians, we are currently recruiting for a Claims Policy & Standards Advisor to join our Provider Relations team. The role will include in office training, after which, the ability to work from both, office and home, on a hybrid basis.

Job Summary

Under the broad managerial direction of the Assistant Manager provide technical advice, subject matter expertise and knowledge transfer to extended health claims department; researching claims that are complex or previously not encountered; representing the Provider Relations on a variety of cross departmental teams and committees; and researches new products and services available in the market place that may impact extended health claims adjudication practices; participates in the review, design, development and implementation of new work methods, procedures, standards and technologies governing department operation.

Job Duties

Extended Health Claims Subject Matter Expert

1. Provides subject matter expertise on all topics related to extended health claims products, processes and policies by:
   1. providing technical advice, subject matter expertise and knowledge transfer to department team members in specific areas of extended health, group and individual benefit plans, claims processing, use of online systems, contract wording, policy interpretation, setting priorities and related areas;
   2. researching claims that are complex or previously not encountered, reviewing member and group coverage, contract limitations, medical information, diagnoses, and practitioner reports; consults with PBC Doctors and Consultants as required and provides advice and direction to make claims adjudication decisions;
   3. researching new products and services available in the market place that may impact extended health claims adjudication practices; surveys other insurance providers to analyze industry trending; assesses administrative impacts to extended health department and makes recommendations on required changes to processes, systems, documentation and training required;
   4. representing Provider Relations on a variety of cross departmental teams and committees, including product development teams, client quote meetings, Canadian Life and Health Insurance Association meetings, and Drug Advisory Committee;
   5. on request, supporting select committees such as Underwriting Review Committee, Benefit Review Committee in researching and providing recommendations;
   6. communicating the need for revised or new department job aids and other learning tools and provides input and feedback to the Learning & Engagement Department on content and approach;
   7. facilitating and generating team department discussion on new products or services ideas being researched or implemented in departments and introduce department initiatives advising on new policies and procedures with the department.
2. Coordinating with Operational Solutions when establishing Service Codes for system and provides input and feedback to the Learning and Engagement Department on content updates.

3. Updating and maintaining the Service Code Reference Manual with new service codes, descriptions, and updating services code changes identified.

Customer, Client and Member Service

4. Receives referrals on complex or sensitive inquiries from internal and external sources, researches the nature of the inquiry, determines appropriate action or additional referral needed to resolve concerns and completes call backs within established department timelines and standards; communicates results of research and related recommendations to appropriate internal department for final decision; approves or recommends exceptions to normal processing of claims within established limits.

5. On a voluntary basis, may attend trade shows associated with conferences or other public forums as a representative of Pacific Blue Cross.

General Team and Department Support

6. Maintains up to date knowledge of facilitation techniques, benefit plans and claims processing rules, policies, procedures, system requirements, terminology and other information related to the provision of extended health claims services to customers, clients and members through continuous learning initiatives.

7. Performs other assigned duties related to the provision of benefit claims services and/or administrative support which do not affect the rating of the job.

Qualifications

• A minimum of 4 years previous related experience including a minimum of 2 years as a Team Leader, Extended Health Claims

• Group Benefits Associate (GBA designation) or equivalent (108 hours)
• High school graduation or equivalent
• Completion of Business Communications (writing skills) course (36 hours or equivalent)
• Completion of Medical Terminology (36 hours or equivalent)

• Typing skills of 40 wpm
• Demonstrated proficiency with Basic Word and Basic Excel

We strive to create a workplace where everyone feels valued and employees feel empowered to freely participate and contribute regardless of race, ethnicity, gender, sexual orientation, religion, ability, education level, parental status, or socioeconomic status. PBC is an equal opportunity employer and welcomes applications from all qualified candidates. To request an accommodation in completing this application, pre-employment testing, interviewing or otherwise participating in the employee selection process, please direct your inquiries to careers@pac.bluecross.ca.