Job Specification

Purpose of Position :

To support the government 'Zero Tolerance for Fraud' policy and the ministry's commitment to data quality and customer service by ensuring only eligible registrants receive access to Ontario health services and monitoring and controlling the accuracy and integrity of the Registered Persons Database.

To support operational efficiencies by participating in the development/implementation of new/enhanced business and system solutions and processing ad hoc requests.

Duties / Responsibilities :

Duties/Responsibilities:

Ensuring clients ongoing entitlement to Ontario health coverage in accordance with related Acts and regulations and registration/eligibility policy and procedures by conducting routine eligibility reviews and creating and maintaining case files and bring-forward systems: determining eligibility status and terminating coverage where necessary and identifying and forwarding potential abuse/misuse cases for investigation in the Eligibility Assessment Officers.

Certifying the integrity and accuracy of the data by investigating and resolving authentication/data maintenance rejects by analyzing reports: identifying and researching discrepancies: communicating with clients or partner jurisdictions to resolve issue and taking appropriate action. Updating RPDB, KTSO and associated online and case tracking system.

Supporting data quality and customer service by monitoring and controlling the integrity of the database by identifying patterns/trends in data errors and compliance with ministry policy and procedures to identify potential training/communication requirements.

Compiles/creates accurate case files for investigation when responding to the MOH 1-888 Fraud line by receiving calls in a professional manner, determining action to be taken, transferring calls to other program areas (i.e. Provider Services Branch, EDT Help Desk etc.) and providing response to general inquiries or public complaints. Recording information in legible format on appropriate data or entering onto case tracking system. Assessing information provided and extracting additional data to support investigation, prioritizing calls for referral to Eligibility Assessment Unit for immediate action.

Participating in the development/enhancement of business and system solutions to improve data integrity and operational efficiencies by identifying and recommending potential improvements/opportunities: analyzing and researching data: developing and testing operational procedures: and working with System Change Control on quality assurance, photo health card and system problem issues.

Providing head office support for RPDB interpretation/research and interpretation/research and processing RPDB updates for internal and external ad hoc requests (i.e. MPP referrals, contentious issues, etc.)

Staffing and Licensing :

• Position requires proficiency in English and French oral and written skills at an advanced level, as per OPS standard.

Knowledge :

Knowledge:
Job requires a thorough knowledge of a range of investigative and research techniques to gather necessary information to establish case files, determine effective dates of coverage, authenticate supporting documents or information and to access eligibility.

Knowledge of relevant section of the Health Insurance Act and regulations, FOIPPA, to protect confidentiality of clients, personal information, Canada Health Act, Human Tissue Act, Immigration Act, Citizenship Act, Health Cards & Numbers Control Act, Vital Statistics Act, the Inter-provincial Agreement, registration and eligibility policies and procedures and buscoms to determine eligibility, advise/resolve issue referred from district offices hotline and other program areas such as MPP inquiries. Contentious issues Officers relating to case files.

Job requires knowledge of ministry programs and services such as the Investigation Unit Provider Services Branch. Ontario Drug Benefits. Health Number Validation and the claims system to respond to inquiries, forward calls where appropriate and research information.

Job requires knowledge of computer system such as RPDB, Charlie Toolkit, KTSO (i.e. mainframe takes such as SARS, Registrar General birth registrations) Internet, Claims Reference File, Case tracking system to interpret research and retrieve information and records to support verification activities or action, update records, end eligibility, apply and remove LOC's and input effective dates of coverage.

Skills :

Skills:
Job requires good analytical and problem solving skills to research and retrieve relevant information, interpret and apply a variety of eligibility and registration policies and procedures in conjunction with requirements of the inter-provincial agreement to assess entitlement and effective dates.

Position requires excellent oral and written communication skills to provide information, explanations and direction to the public and provide clear instructions and interpretation of eligibility/registration policies and authentication/verification requirements relating to case files to district office. Hotline and other program staff members. Oral communication skills to respond to clients and extracting pertinent information from callers on the ministry's fraud line and participating in information sessions at district offices when providing overviews of verification activities and responsibilities. Written communication skills to maintain case files, send routine eligibility letters for investigation, documenting actions, preparing option papers and drafting correspondence.

Job requires interpersonal skills to work in a team environment, respond to urgent request for assistance from district offices and staff in other program areas.

Arithmetic skills are required to complete monthly productivity statistics.

Freedom of Action :

Job requires working in accordance with ministry and government policies, guidelines and directives to determine client's entitlement to Ontario health coverage.

Position requires determining action to be taken and eligibility/registration requirements to obtain Ontario health coverage.

Job requires independent decision making, under the general direction of the Group Leader or Supervisor to ensure the correct policy/procedure has been applied when confirming or denying eligibility and ensuring cases are actioned in a timely manner and that deadlines are met on urgent requests.