Job Description
PBC Solutions is looking for Medical Claims Adjudicators to join our growing team at our Greater Victoria office! This position requires in-office training for a period of up to 12 months. Following the successful completion of this training there may be an opportunity for this position to be a hybrid role, and regular presence at the office will be required. About PBC Solutions: PBC Solutions has been recognized as one of British Columbia's 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 medically-necessary 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 in-training 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 expert-level 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 third-party 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 third-party 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 third-party requesters
- May audit submitted claims to ensure billing integrity and accuracy
- Update Cheque Exception Lists and Reject Lists
- Correspond with general public, practitioners, and third-party 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
Answer public and provider calls - Articulate client policies clearly, neutrally, and quickly
- Assist callers in the use of on-line 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
Understand and comply to policies/procedures set by PBC Solutions, legislation, and our clients - 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 non-compliance of policies and procedures, regardless of the cause
Adhere to your work commitment and daily schedule - 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
Manage your interactions with callers, clients, and colleagues respectfully, collaboratively, and professionally to contribute to a harmonious, productive work environment - Articulate concerns, ideas, and opinions in a professional manner
- De-escalate emotionally charged situations/calls
- Utilize pro-social skills (sharing, taking turns, manners, negotiation, problem solving, smiling, Impulse control, interrupting/listening, dealing with mistakes, making decisions, etc.)
- Other duties as needed
Required Education and Experience - High school diploma or GED equivalent
- Intermediate level of MS Office Suite
- Required minimum of two years’ previous related experience in a customer service-oriented administration position, including dealing with customer inquiries over the phone and in person
- An equivalent combination of education and experience may be considered.
Preferred Qualifications - Preferred experience as a billing clerk in a medical setting
- Preferred experience in claims adjudication
- Preferred experience in the health sector
Knowledge, Skills, and Abilities - 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 .
Required Competencies - Effective Communication
- Feedback
- Ensuring Accountability
- Problem Solving
- Multiple Demands and Time Management
- Customer Focus
- Decision Quality
- Teamwork
- Innovation
What's in it for you
We offer a robust health & dental benefits plan, with flexible options that will meet you and your family's 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, pre-employment testing, interviewing or otherwise participating in the employee selection process, please direct your inquiries to hr@pbcsolutions.ca
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 you've found your ideal work environment - Apply today please! We'd 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 2 , 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 other’s 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 open-minded 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.
Solution-oriented – We see possibilities rather than limitations. We use our diverse capabilities to develop options to resolve our challenges.
Job Tags
Flexible hours,