Medical Adjudication jobs

Alberta Blue Cross® is an Alberta based organization dedicated to delivering exceptional customer experience and community leadership. We’re committed to providing the best health coverage to over 1.8 million members and take an active role in promoting wellness. We believe in what we do—and place trust in our employees to deliver our vision.

Working at Alberta Blue Cross® means having a career where you’ll be recognized for your contributions. We value diversity, encourage our team members to maintain a healthy work-life balance and provide opportunities for career growth.

OVERVIEW:

Our Special Authorization Analyst II team is growing. This position plays a critical clinical decision-making role in assessing Special Authorization requests and determining appropriate medication coverage within established standards. Special Authorization is a process where prescribers can request coverage for specific drugs for their patients, and this role requires clinicians to apply evidence-based guidelines, clinical judgment, and a strong understanding of member needs to support timely access to medications.

WHAT YOU WILL DO:

• Apply clinical expertise to assess Special Authorization requests, determine eligibility for requested drug therapies, and make decisions that directly impact member access to medications.
• Interpret clinical information, accepted medical conditions, and plan criteria to ensure decisions are accurate, consistent, and clearly documented.
• Record decision rationale and required information in Alberta Blue Cross® computer systems to support appropriate claims adjudication and continuity of member access.
• Prepare clear, clinically informed correspondence for prescribers and subscribers regarding Special Authorization decisions.
• Respond to electronic and telephone inquiries from internal and external customers by explaining decision outcomes, requirements, and next steps in a professional and member-focused manner.
• The ability to work occasional weekdays until 5:00 pm, weekends, and statutory holidays on a rotation basis is required.

WHAT YOU WILL HAVE:

• Preferred post-secondary education in Pharmacy, Pharmacology, Health Sciences, Nursing, or similar clinical disciplines. Or, experienced Pharmacy Technicians and existing special authorization professionals.
• Knowledge of pharmacotherapy, disease states, treatment guidelines, drug reimbursement principles, and clinical decision-making.
• Preferred experience in Special Authorization, drug benefits administration, pharmacy practice, formulary management, drug utilization review, or health insurance adjudication.
• Strong analytical, problem-solving, and decision-making skills.
• Ability to manage time effectively, work independently, and contribute to a collaborative team environment.
• High degree of accuracy, attention to detail, and commitment to quality work.
• Proficiency with Microsoft Office, including Word and Excel; Access experience is considered an asset.
• Excellent written and verbal communication skills, supported by strong organizational abilities.
• Ability to adapt to changing priorities and manage competing demands in a fast-paced environment.
• Collaborative team player with a positive and flexible approach.
• Service-oriented and responsive, with the ability to build and maintain effective relationships with internal and external customers.

IDEAL CANDIDATE PROFILE:

• This role is well suited to pharmacology graduates, experienced pharmacy technicians, and drug benefits professionals who are looking to apply their medication knowledge in a meaningful alternative career path outside of traditional dispensing or frontline pharmacy practice.
• The ideal candidate is someone who enjoys analyzing clinical information, applying drug coverage criteria, and making thoughtful, evidence-informed decisions that influence whether members can access the medications they need.
• This opportunity may be especially attractive to experienced clinicians and pharmacy professionals seeking a role that offers clinical complexity, meaningful member impact, and the ability to contribute to medication access without the demands of a retail, hospital, or direct patient-care environment.

This position will remain open until a suitable candidate is selected.

Alberta Blue Cross® is an inclusive employer committed to a workplace that reflects the diversity of the communities we serve. We empower and are advocates for our team members by welcoming, respecting and valuing their unique perspectives, backgrounds, and experiences.

We offer the opportunity to work in an innovative, high-energy team-focused environment. If you have the qualifications we are looking for, apply online at careers.ab.bluecross.ca

A criminal record check satisfactory to Alberta Blue Cross will be required as a condition of employment, following a conditional offer.