Medical Benefits Enquiries Customer Service Representative (Regular Full-time)

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

The Medical Claims Enquiries Customer Service Representative (CSR) reviews, researches and responds to enquiries within a call centre environment. Calls can regard medical benefits, claims submissions, payments for healthcare professionals, hospitals, clinics, laboratories and the general public. This work involves reviewing and discussing patient and practitioner information, so therefore, requires an extremely high level of privacy adherence, accuracy and professionalism.

The CSR explains claims rules as published within the Medical Services Commission Payment Schedule and provincial healthcare policies. In order to discuss a claim with a caller, CSR’s often need to have a fair understanding of medical terminology and have a logical approach to problem solving.

This position is designated as a Grid level 14, with an hourly range of $32.20 - $36.65.

Primary Duties

1. Answer public and provider calls
2. Articulate client policies clearly, neutrally, and quickly
3. Assist callers in the use of on-line forms and in submitting applications/documentation/claims
4. Control calls (paraphrase, actively listen, empathize, act)
5. Update IT systems with validated provider information
6. Troubleshoot provider connectivity problems, and determine solutions
7. Electronically issue patient files and remittance statements
8. Delete medical claims that are submitted in error
9. Utilize situational judgment skills
10. Resolve escalations (transfers) from other departments
11. Perform repetitive tasks and answer repetitive questions
12. Use a computer for long periods of time

Process requests for reimbursements and documents provided from Providers and Public

1. Validate information and documentation provided by the public and providers, reject or accept Applications and requests, as appropriate
2. Apply the HIBC policies that pertain to the form/correspondence you are processing, at the level of work you are assigned, then update our IT systems accordingly
3. Release (or not) personal information to 3rd Party Requesters
4. Correspond with public/providers to explain policy decisions and to seek or provide information

Process requests for medical histories

1. Validate information and documents provided by public
2. Make decisions on and initiates reimbursements directly to beneficiaries
3. Interpret and use medical information in accordance with the Medical Services Commission Payment Schedule and Supplementary Benefits Schedules
4. Verify that cheques have not been cashed, sends out affidavits for beneficiary to sign and return stating the money was not received
5. Correspond with public/providers to explain adjudication decisions or request additional information

Understand and comply to policies/procedures set by PBCS, legislation and our clients

1. Comply to all regulations, policies and procedures, with minimal intervention
2. Learn new policies, procedures and computer applications within designated timelines
3. Escalate work that is beyond the level you are assigned
4. Obtain required approvals from designated personnel
5. Document notes and actions, in our systems, that are clear, objective and useful to others
6. Utilize designated channels and systems for making recommendations, communicating, reporting, etc.
7. Report non-compliance of policies and procedures, regardless of the cause

Adhere to your work commitment and daily schedule

1. Manage personal time with minimal impact to work time
2. Track and update weekly/monthly schedule expectations, as they are relayed
3. 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.
4. Perform the work you are assigned within the designated time
5. 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

1. Articulate concerns, ideas and opinions in a professional manner
2. De-escalate emotionally charged situations/calls
3. Utilize pro-social skills (sharing, taking turns, manners, negotiation, problem solving, smiling, impulse control, interrupting/listening, dealing with mistakes, making decisions, etc.)
4. Other duties as assigned

Required Education and Experience

1. High school diploma or GED equivalent including a 65% grade in Grade 12 English and Math, required, may be subject to standardized testing
2. Intermediate level of the MS Office Suite applications
3. Minimum 1 year of experience working in a call centre environment providing customer service, practicing protection of privacy and information, and the ability to communicate in a professional manner orally and in writing.
4. An equivalent combination of education and experience may be considered.

Required Competencies

1. Effective Communication
2. Managing Diverse Relationships
3. Organizational Savvy
4. Multiple Demands and Time Management
5. Conflict Management
6. Customer Focus
7. Balancing Stakeholders
8. Decision Quality

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 tohr@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 22, 2025 by 4:00 PM PST. An eligibility list may be established for this position.