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Business Rules Specialist At Workplace Safety and Insurance Board

Location: Toronto, Ontario

Job Description

The WSIB’s Health Services Division is a key partner in the organization’s strategic transformation initiatives supporting the integration of recovery and return to work of injured and ill workers in Ontario.

Within the Health Services Division, there is a need for a Business Rules Specialist to provide in-depth analysis on health care/labour market re-entry business rules usage, relevance, and opportunities for change/improvement. Identify trends and emerging issues that may impact on rising costs or business processes and evaluate the impact on WSIB’s health care/labour market re-entry business. Review business rule change requests and develop recommendations for implementation.

Lead business rule change request process and develop recommendations for implementation.

Provide in-depth technical analysis on health care/labour market re-entry business rules usage, relevance, and opportunities for change/improvement.

Analyze and resolve complex billing issues raised by internal or external stakeholders.

Identify trends and emerging issues that may impact on rising costs or business processes and evaluate the impact on WSIB’s health care/labour market re-entry business.

Review business rule change requests and develop recommendations for implementation.

Major Responsibilities:

1. Research, analyze, test (by developing scripts/scenarios), and monitor new and existing business rules to identify utilization trends and emerging issues/patterns, to evaluate the impact on the WSIB’s health care/labour market re-entry business as it relates to program/service delivery and financial risks, and to identify requirements to change business rules.

2. Prepare detailed and analytical statistical reports for Health Services Management and Labour Market Re-Entry Management/Work Reintegration on analysis results, on organizational impacts and opportunities for continual improvement, and on areas for further analysis including an action plan to address changes to business processes and/or emerging trends/issues by:

  • Conducting trend analysis, developing appropriate criteria for analysis, and providing statistical information by sector and geographic location on health care and labour market re-entry costs;
  • Creating unique billing profiles for health care professionals, health care suppliers, labour market re-entry/work reintegration providers and workers.

3. Act as an expert resource to internal clients on the impacts and financial risks of proposed rule changes and help clients understand the relationships between existing and proposed business rules. Liaise and communicate with internal clients to inform them of new or changed business rules or processes.

4. Participate in the vendor relationship by:

  • Leading work with the external payment processor to update the Provider Bill Approval System (PBAS) (i.e. business rules changes, provider fee increases, new fee/program);
  • Facilitating the implementation of rules changes to ensure timely and accurate testing, monitoring, and implementation;
  • Maintaining comprehensive documentation related to change requests.

5. Partner with IT to monitor the integrity of PBAS by:

  • Identifying and resolving system problems related to business rules;
  • Ensuring all health care/labour market re-entry/work reintegration rules and on-line fee schedules are current and operational;
  • Planning, co-ordinating, testing, and implementing changes to rules.

6. Participate in branch or cross-divisional projects by:

  • Providing expertise relating to PBAS rules;
  • Assisting in establishing action points, developing work plans, assembling the team, and delegating responsibilities;
  • Assisting with monitoring project progress and providing direction to project team members;
  • Assisting with implementing (or making recommendations for implementing changes) and evaluating project outcomes.

7. Partner with Learning and Development/Operations to assist in identifying staff learning requirements/opportunities, to provide feedback on learning evaluation, and to ensure PBAS payment processing and rules administration training is current and accurate.

8. Perform other related duties as required or assigned.

Job Requirements:

  • University completion at an undergraduate level.
  • 6 years prior experience in the areas of adjudication and health care.
  • Demonstrated knowledge of healthcare systems, processes and healthcare administration including knowledge of healthcare best practices, products and tools.
  • Demonstrated knowledge of diagnostic codes, coding standards and guidelines, billing processes, claims registration, and medical terminology.
  • Demonstrated analytical, research, problem solving and information gathering skills.
  • Proficient with MS Office (Word, PowerPoint, Excel).

As a precondition of employment, the WSIB will require a prospective candidate to undergo a criminal records name check prior to or at any time following hire.

To apply for this position, please submit your application by the closing date noted above.

We appreciate the interest of all candidates. Due to the volumes of applications we receive, we are only able to contact candidates that are selected to move forward in the recruitment process. The WSIB is an equal opportunity employer.

The WSIB is an equal opportunity employer and provides accommodation for job applicants in accordance with the Human Rights Code and the Accessibility for Ontarians with Disabilities Act. If you are an individual with a disability and you need accommodation in order to apply for this position, please contact If you are invited to participate in the assessment process, please provide your accommodation needs at that time. Please be advised that you may be required to provide medical documentation to the WSIB’s Corporate Health Department so that appropriate accommodation can be provided to you throughout the recruitment process.

Employees of the WSIB have important ethical responsibilities, including the obligation to place the public interest above personal interests. Job applicants are therefore required to disclose any circumstance that could result in a real, potential or perceived conflict of interest. These may include: political activity, directorship or other outside employment and certain personal relationships (e.g. with existing WSIB employees, clients and/or stakeholders). Please contact TAC if you have any questions about conflict of interest obligations and/ or how to make a disclosure.

Privacy Statement

Personal information will be collected from your resume, application, cover letter and references under the authority of the Workplace Safety and Insurance Act, 1997 and will be used by the Talent Acquisition Centre and WSIB hiring parties to assess/validate your qualifications and/or determine if you meet the requirements of vacant positions and/or gather information relevant for recruitment purposes. If you have questions or concerns regarding the collection and use of your personal information, contact the WSIB Privacy Office, 200 Front Street West, Toronto, ON, M5V 3J1 or 416-344-5323 or 1-800-387-0750 extension 5323. Be advised that information related to application status will not be provided.