Medical Adjudication jobs in Remote

About Pacific Blue Cross
Pacific Blue Cross (PBC) is British Columbia’s leading health benefits provider, dedicated to improving the health and wellbeing of members and communities across the province. Guided by values of collaboration, accountability, integrity, and innovation, PBC fosters a culture of continuous improvement and service excellence. With a strong focus on digital modernization, operational efficiency, and enhanced member experiences, PBC is transforming how it delivers value to its members and partners.

Perks

• Work-life balance with flexible working hours of 7 hours per day, Monday to Friday (i.e., 35 hours per week).
• Paid vacation starts at 3 weeks per year, and increases with years of service.
• Hybrid work environment (i.e., a combination of work from office and work from home days).
• Generous benefits, including extended health, dental, and life insurance; these benefit premiums are 100% paid by PBC.
• Company pension contributions after 1 year of service.
• Education allowance up to $1,000 per calendar year.
• Onsite gym, cafeteria, and access to virtual doctors/counsellors 24/7 via our Employee Family Assistance Program!

About The Position

• We are searching for a permanent Disability Claims Specialist to join our Life and Disability team.
• This position is unionized and part of the CUPE 1816 Bargaining Unit. This position is paid at hourly rates and receives wage increases in accordance with the Collective Agreement. The wage for this position starts at: $5,177 per month ($62,124 annual equivalency) and has increases up to $6,042 per month ($72,504 annual equivalency).

Under the general supervision of the Supervisor, Work and Wellness (W&W), the Disability Claims Specialist provides professional disability claims services to clients and applicants including reviewing, analyzing, and investigating claims information from a variety of sources, determining adjudication and assessment actions required to process short-term disability claims and initiating referrals or escalation to other internal or external disability resources where intervention or case management is required. This position prepares and presents pending short-term disability claims and related recommendations to the disability team for discussion and review. This position monitors and updates active claims on an ongoing basis and communicates claims-related decisions directly to clients and applicants. This position generates payments for authorized short-term disability claims.

Key Ways This Position Makes An Impact

Work & Wellness Disability Claims Adjudication and Assessment

1. Provides professional disability claims services to clients and applicants undergoing review to ensure claims are coordinated within contractual terms and conditions of eligibility and coverage by:

a. reviewing, analyzing, and investigating claims and history/conditions of claimants to determine eligibility information from a variety of sources as well as requesting and documenting additional information as required.

b. interpreting and applying contract wording, medical documentation, claims policies and procedures, statutory requirements and other guidelines affecting valuation and disposition of short-term disability claims.

c. initiating regular telephone contact with claimants, policy-holders, employers, doctors, lawyers, brokers, third parties and other stakeholders in the disability claims process to gather additional information, including the application of appropriate questioning techniques to obtain information determining level of functioning, determining status of accommodation, and return-to-work options.

d. planning the content of and composing a variety of written correspondence and documents which adhere to the established standards of business communications and internal style guidelines.

e. adjudicating claims including keying claims data into claims processing systems, documenting all contacts made and actions taken, processing payments, providing claim updates, and maintaining files. Referring claims to other internal or external disability stakeholders where intervention or case management is required.

f. acting as liaison with Finance on third party claims to ensure overpayments are identified and followed up, or on an occasional basis, manually calculating amounts owing based on policy provisions.

g. identifying and calculating amounts for recovery where WorkSafe benefits, other sources of income/benefits, motor vehicle accidents prior to 2019, or earlier than expected return to work have or may result in overpayment; communicates recovery amounts and expectations for repayment to all affected parties, and follows up to ensure collection.

2. Prepares and presents pending short term disability claims and related recommendations to the disability team for discussion and review. Supports findings and justifies acceptance or denial of claim, including presentation of options for more complex and/or subjective conditions and considerations.

3. Monitors and updates claims on a continual basis, identifies impact of changing conditions or unforeseen circumstances and determines required actions including recommending suspension of benefits. Communicates claims-related decisions directly to clients and applicants, and composes written correspondence containing details of decisions including reasons for denial.

4. Generates payments for approved short-term disability claims to ensure claimants receive accurate and timely benefits payments consistent with policy provisions and claims procedures including:

a. verifying salary and setting up tax and other applicable deductions.

b. verifying initial payment dates and related offsets.

c. entering claimant notes for inclusion on the Explanation of Benefits (EOB).

d. monitoring gradual return to work dates and identifying impacts on payments.

e. monitoring pending garnishees and adjusting payments as required.

f. setting up auto payments for approved future payment dates.

g. making payment adjustments in accordance with policy.

h. communicating with stakeholders to update their information and the claim as required.

Customer, Client, and Member Service

5. Consistent with Work & Wellness’s service level objectives, responds to a variety of general inquiries by phone and email to maintain client relationships and client retention.

General Team and Department Support

6. Logging statistics for productivity metrics.

7. Maintains up-to-date knowledge of disability management practices, policies and procedures, system requirements and other information related to the provision of disability management services through continuous learning initiatives.

8. On a one-to-one basis, supports new employees by demonstrating the execution of specific tasks and duties, and sharing knowledge and experience on request.

9. Performs other assigned duties related to the provision of disability claims, adjudication and administrative support services which do not affect the rating of the job.

Key Experiences You Bring To This Role

• High school graduation, or equivalent.
• Completion of a 1-year Disability Management Diploma (288 hours), or equivalent.
• Demonstrated proficiency in basic Word and Excel.
• Typing skills of 40 wpm.
• 2 years of previous related experience, including 1 year in a Disability Claims Administrator, W&W or Benefit Representative, EHC/Dental positions, or equivalent.
• Demonstrated decision making and critical thinking skills.
• Demonstrated oral/written communication skills.

If you’re excited about taking on this opportunity, we invite you to apply today and start the conversation with us about this position.

While we thank all applicants for their interest, only short-listed candidates will be contacted.

Diversity, Equity, and Inclusion

PBC is an Indigenous Works employer of choice, an Insurance Business Canada Diversity, Equity, and Inclusion award winner, one of Canada’s Greenest employers, a Canadian Centre for Diversity and Inclusion (CCDI) employer partner, and a Pride at Work partner.

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. We are an equal opportunity employer and welcome applications from all qualified candidates.

To request an accommodation in completing this job application, testing, interviewing, or otherwise participating in the employee selection process, please direct your inquiries to careers@pac.bluecross.ca. These accommodation requests will be reviewed confidentially and, on a case-by-case basis by Human Resources.

Pay: $5,177.00-$6,042.00 per month

Benefits:

• Company events
• Company pension
• Dental care
• Disability insurance
• Employee assistance program
• Extended health care
• Life insurance
• On-site gym
• On-site parking
• Paid time off
• Vision care
• Wellness program
• Work from home

Work Location: Hybrid remote in Burnaby, BC V5G 4W6