Claims Adjudicator

Responsibilities

The Health Insurance Programs Branch (HIP) administers the Alberta Health Care Insurance Plan (AHCIP), ensuring eligible Albertans, practitioners, and facilities receive insured health benefits in accordance with provincial and federal legislation.

Reporting to the Team Leads of the Provider Claims, Professional and Facilities Management or Out of Province - Special Programs, the adjudicator assesses medical and hospital claims submitted by service providers, Alberta residents, and secondary insurance companies. The role interprets legislation, policies, governing rules, the Alberta Schedule of Medical Benefits, and other provincial and foreign health fee schedules to determine appropriate payment, adjustment, or refusal of claims.

The position reviews complex supporting documentation, investigates claim issues, applies currency conversions, and communicates decisions clearly and professionally. As with other claims adjudication roles, success requires strong medical terminology, research, analytical, problem-solving, communication, customer service, and workload-management skills in a high-volume environment.

Responsibilities

• Assess and adjudicate in-province physician claims, out of province claims of varying complexity, ensuring accurate application of legislation, policies, governing rules, and benefit schedules.
• Review medical reports, invoices, and other supporting documents; interpret provincial and foreign fee schedules and billing practices; and equate services to comparable Alberta health service codes.
• Research and resolve claim discrepancies, verify eligibility and approvals, apply currency conversions, and determine appropriate action for complex or problematic claims.
• Process approved Out-of-Country Health Services Committee and Special Programs invoices in accordance with established requirements and time-sensitive payment schedules.
• Provide accurate, timely, and empathetic service to Alberta residents, health service providers, secondary insurance companies, other provincial health plans, and internal stakeholders regarding coverage and claim decisions.
• Carry out key operational duties related to practitioner’s enrollment and billing administration for the Professional and Facility Management Unit.
• Assess practitioner submissions to ensure completeness and accuracy, verify credentials, permits, corporate documentation, and other supporting materials, and ensure compliance with program requirements.

Support consistent adjudication and continuous improvement by identifying issues, recommending process or system enhancements, maintaining reference tools, and contributing to team training, coaching, and quality control.

The is provided for further details on this position.

APS Competencies

Competencies

are behaviors that are essential to reach our goals in serving Albertans. We encourage you to have an in depth understanding of the competencies that are required for this opportunity and to be prepared to demonstrate them during the recruitment process.

Systems Thinking

: Demonstrates a broad understanding of how claims adjudication decisions impact program integrity, client outcomes, operational processes, and compliance across Alberta's health system.

Drive for results

: Delivers accurate, timely results in a high-volume environment while meeting performance targets and maintaining a strong focus on service excellence.

Build Collaborative Environments

: Contributes to a positive and inclusive team culture by sharing knowledge, supporting colleagues, and working collaboratively to achieve operational goals.

Develop Networks

: Builds and maintains effective relationships with Alberta residents, health service providers, secondary insurance companies, other provincial health plans, and internal program partners to support timely and accurate claims administration.

Qualifications

High school diploma plus a minimum of four years of progressively responsible related administrative experience.

Equivalencies will be considered on the basis of one year of education for one year of experience, or one year of experience for one year of education.

Preferred Experience

• Experience interpreting medical and dental terminology, anatomy, and surgical and non-surgical procedures to support complex claims assessment and adjudication.
• Knowledge of Alberta's Schedule of Medical Benefits, governing rules, health legislation, regulations, policies, and procedures, and their application to claims adjudication.
• Experience reviewing medical reports, invoices, statements of account or assessment, and other supporting documentation to make accurate claim payment decisions.
• Experience researching and resolving complex claim issues, interpreting benefit coverage, and communicating decisions clearly and professionally to clients and stakeholders.
• Experience with out-of-province or out-of-country medical or hospital claims, provincial or foreign fee schedules, currency conversion, portability of coverage, or secondary insurance coordination is an asset.
• Proficiency using claims management systems, document management tools, and Microsoft Office applications (Word, Excel, Outlook, and SharePoint) while managing detailed, high-volume work.

Minimum recruitment standards

outline the minimum education and experience required for appointment to a job classification.