Claims Adjudicator

Government of Alberta; Edmonton; On-site; CAD 59,000 - 75,000; Full time

Job summary

The Government of Alberta is seeking a Claims Adjudicator in Edmonton. This role administers the Alberta Health Care Insurance Plan (AHCIP) and adjudicates in-province and out-of-province claims, ensuring accurate payment decisions in a high-volume environment.

Reporting to HIP leaders, you will interpret legislation, review medical documentation, apply provincial and foreign fee schedules, and communicate outcomes to stakeholders with professionalism.

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.
• 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.

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.

Skills

Medical terminology

Research

Communication

Education

High school diploma

4 years admin experience

Tools

Claims management systems

Microsoft Office

Job description

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Job Information
Job Title: Claims Adjudicator
Job Requisition ID: 88004
Ministry: Primary and Preventative Health Services
Location: Edmonton
Full or Part-Time: Full-time
Hours of Work: 36.25 hours per week
Permanent/Temporary/Wage: Multiple Positions – Permanent/ Temporary
Scope: Open Competition
Closing Date: October 22, 2026
Classification: Administrative Support 6
Salary: $2,265.79 to $2,866.95 bi-weekly ($59,137 - $74,827/year)
The Alberta Public Service works to build a stronger province for current and future generations. We make a difference in the lives of Albertans through rewarding and diverse career opportunities.

The Health Insurance Programs Branch administers the Alberta Health Care Insurance Plan (AHCIP) in compliance with Alberta and Canadian legislation and policy. Provider Relationship and Claims supports accurate and timely payment of health claims to practitioners and residents, including specialized out-of-province and out-of-country programs for Albertans who receive medically required health services outside Alberta or Canada.

Role 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.

• 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 Job Description is provided for further details on this position.

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.
  

Hours of Work: Monday to Friday 8:15 AM – 4:30 PM, 36.25 hours per week.

Location: ATB Place North, 10025 Jasper Avenue, Edmonton

Six permanent full-time positions and two temporary full-time positions are available. One temporary position is expected to end in December 2026, and the other is expected to end in May 2027.

This competition may be used to fill future vacancies, across the Government of Alberta, at the same or lower classification level.

Additional requirements:

• A cover letter outlining why you are applying to this role and how your experience relates to the qualifications is required.
• The final candidate for this position will undergo appropriate pre- employment checks including academic credentials check and references checks.

Links and information on what we have to offer:

• Positive workplace culture and work-life balance.

We thank all applicants for their interest. All applications will be reviewed to determine which candidates' qualifications most closely match the advertised requirements.