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CLAIMS ADJUD.

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CLAIMS ADJUD.

  1. 1. Page 1 of 3 PROGRAM: The Out of Province Claims branch is responsible for the adjudication and payment of hospital benefits for eligible British Columbia residents receiving hospital care outside the province. The Branch also provides a centralized service for interprovincial billings submitted by British Columbia hospitals for services provided to residents of other provinces/territories. These services are provided within the parameters and regulations of the Hospital Insurance Act, Reciprocal Billing Agreements, Acute Care Policy Manual, Interprovincial Agreement on Eligibility and Portability of Hospital and Medical Care Insurance, Medicare Protection Act and the Core Policy and Procedures manual. PURPOSE OF POSITION(S): These positions are responsible to process reciprocal and nonreciprocal interprovincial hospital billings and claims between British Columbia (BC) hospitals, other provinces/territories and BC residents. POSITION LINKS: These positions report to the Program Administrator, Out of Province Claims and work in a high- volume environment characterized by highly sensitive information. Accuracy, efficiency, security of information and processing claims on a timely basis is required. The positions interact with both internal and external clients including: - Hospital personnel - Claimants - Counterparts in other Provinces/Territories - General Public - Other Government Agencies - Health Insurance BC POSITION NUMBERS: DIVISION: UNIT: 30911, 30488, 30938 Finance and Corporate Services Accounting Operations/Out of Province Claims CURRENT CLASSIFICATION: Clerk 9 DESCRIPTIVE WORK TITLE Claims Adjudicator SUPERVISOR’S POSITION 30883 SUPERVISOR’S DESCRIPTIVE WORK TITLE Program Administrator, Out of Province Claims SUPERVISOR’S CLASSIFICATION: AO 18 MINISTRY OF HEALTH JOB DESCRIPTION
  2. 2. Page 2 of 3 ACCOUNTABILITIES: 1. Adjudicate and process interprovincial reciprocal hospital billings from BC Hospitals for non- residents of BC and issue invoices to other provinces/territories for payment: - Review and approve/deny override requests from BC Hospitals - Generate and process invoices to pay BC Hospitals and receive payment from other provinces - Assess, investigate and accept/deny adjustments to claims requested by other provinces/territories and/or BC Hospitals, complicated claims referred to Program Administrator 2. Adjudicate and process interprovincial reciprocal and pre-approved non-reciprocal hospital billings incurred by BC residents while in other provinces/territories: - Enter hospital claims data both manually and through electronic file download into the Hospital Out of Province Claims system - Generate and process invoices to pay other provinces, hospitals or claimants - Review declarations and hospital claims to determine eligibility of claimants to receive hospital benefits, request adjustments from BC Hospitals for ineligible claims - Assess, investigate and accept/deny adjustments to claims requested by other provinces/territories, complicated claims referred to Program Administrator 3. Answer inquiries, verbally and in writing regarding out of province hospital billing claims status and procedures from hospital personnel, claimants, general public and other government agencies. 4. Process and distribute incoming mail/faxes and complete office filing. 5. Record invoices and payments from other provinces/territories. 6. Update data bases for reporting purposes. 7. Receive, log and reroute requests for non reciprocal services. 8. Assist the Program Administrator with system testing of regular daily transactions and procedures, as required. 9. Assist the Program Administrator with peer to peer training, as required.
  3. 3. Page 3 of 3 QUALIFICATIONS: Education: Secondary school graduation or equivalent Experience: Clerical/administrative support experience, 1-2 years preferred, demonstrated experience with data entry. Knowledge: Knowledge of legislation, regulations and policies governing the program, including but not limited to: Hospital Insurance Act, Reciprocal Billing Agreements, Interprovincial Agreement on Eligibility and Portability of Hospital and Medical Care Insurance. Knowledge of hospital claims manual Skills:  Ability to work in a team environment  Ability to be tactful and diplomatic in dealing with confidential medical material  Use computerized financial systems  Strong keyboarding skills  Provide and obtain clear, concise and complete oral and written information  Produce highly accurate work with attention to detail in a timely manner. BEHAVIOURAL COMPETENCIES  Information Seeking is driven by a desire to know more about things, people or issues. It implies going beyond the questions that are routine or required in the job. It may include "digging" or pressing for exact information; resolution of discrepancies by asking a series of questions; or less-focused environmental "scanning" for potential opportunities or miscellaneous information that may be of future use.  Service Orientation implies a desire to identify and serve customers/clients, who may include the public, co-workers, other branches/divisions, other ministries/agencies, other government organizations, and non-government organizations. It means focusing one's efforts on discovering and meeting the needs of the customer/client.  Teamwork and Co-operation is the ability to work co-operatively within diverse teams, work groups and across the organization to achieve group and organizational goals. It includes the desire and ability to understand and respond effectively to other people from diverse backgrounds with diverse views.  Results Orientation is a concern for surpassing a standard of excellence. The standard may be one’s own past performance (striving for improvement); an objective measure (achievement orientation); challenging goals that one has set; or even improving or surpassing what has already been done (continuous improvement).  Listening, Understanding and Responding is the desire and ability to understand and respond effectively to other people from diverse backgrounds. It includes the ability to understand accurately and respond effectively to both spoken and unspoken or partly expressed thoughts, feelings and concerns of others. People who demonstrate high levels of this competency show a deep and complex understanding of other, including cross- cultural sensitivity.

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