- Job Title: AISH Adjudicator
- Work Unit: Delivery Services
- Ministry: Alberta Community and Social Services
- Competition Number: 1053381
Within the Assured Income for the Severely Handicapped (AISH) program the AISH Adjudicator is a key position reporting to an AISH Adjudicator Team Lead. The AISH Adjudicator has the sole authority, as delegated by the Director, to determine medical eligibility for the AISH program. The AISH Adjudicator also has the sole authority, as delegated by the Minister to determine financial hardship eligibility in circumstances when one cohabiting partner is residing in a facility. The AISH Adjudicator is responsible for ensuring that medical eligibility is adjudicated in an objective, equitable, and timely fashion. If deemed eligible, applicants have a potential of receiving AISH benefits for over 47 (ages 18-65) years which translates to a significant financial and medical indemnity to the province. The current average financial indemnity to the Government of Alberta (GOA) over 47 years is $2.9 million per client indexed at 3%.
AISH applications highlight complex and comorbid medical conditions reflective of the medical, psychological, psychiatric, neurological, developmental, cognitive, and addiction domains which are typically compounded by social factors. The AISH Adjudicator possesses a diverse understanding of how concurrent medical conditions impact one's ability to earn a livelihood pertaining to the AISH Act and Regulation. The AISH Adjudicator must apply legislation and interpretation to the adjudication process to determine eligibility as it pertains to a 'severe handicap’. Fundamental to adjudicating multi-faceted medical conditions is awareness of treatment modalities, remedial therapy, vocational approaches, and employment and training options. This position demonstrates strong critical thinking, judgement, independence, accuracy, and decision making skills that are exemplified by research, analysis, consultative and collaborative approaches, investigative, and conceptual skills that are organized within detailed writing abilities.
The AISH Adjudicator also provides reviews of medical eligibility decisions for appeals and delivers written communication of the decision and rationale to Albertans, provincial AISH Appeal Panels, Delivery Supports, Regional AISH staff, and other Corporate Resources.
The AISH Adjudicator has other key responsibilities within the AISH program which includes; consulting and reviewing documentation received from internal medical and psychological contracted resources, attending debriefings of psychological assessments as required, facilitating the AISH Benefits Administration Program, determining commencement dates for AISH benefit eligibility, determining medical eligibility and commencement date appeals for AISH Appeal Panels, and preparing and drafting ministerial communication regarding processes.
Responsibilities and Activities
Adjudicate medical eligibility for the AISH program by:
- Determining the relationship between diagnosis(es), prognoses, and an applicant's ability to earn a livelihood by assessing relevant medical evidence and non-medical information, such as remedial rehabilitation and employment training options, against legislation to determine eligibility.
- Interpreting medical evidence and non-medical information to render consistent decisions on eligibility (initial, reconsideration, and ongoing eligibility) and identifying when further medical documentation is required to support the adjudication process.
- Understanding vocational rehabilitation and approaches from a disabilities perspective to support the adjudication process and how remedial therapy affects one's ability to earn a livelihood.
- Collaborating with internal stakeholders (i.e. AISH Adjudicator Team Leads, AISH Adjudicators, Supervisors, AISH Generalists) and external stakeholders (physicians, psychiatrists, nurses, social workers, community based programming) when required.
- Researching medical conditions, remedial therapy, and treatments available, and trends.
- Understanding and determining the most appropriate assessment to pursue based on the medical information submitted. Assessments include: Psychological/Disability, Neuropsychological, Psychiatric, Chronic Pain, Cognitive, Functional Capacity, Vocational and/ or a combination of the aforementioned.
- Consulting with the AISH Medical Consultant when needed to support interpretation of medical evidence.
- Providing communication that rationalizes a detailed decision as it relates to the applicant's ability to earn a livelihood.
- Determining the commencement date for medical eligibility on: initial applications, applications that arc overturned by the AISH Appeal Panel, and confirming or varying the commencement date for clients in receipt of AISH benefits as per the appeals process. Completing additional Medical Reviews on AISH applications when new information is provided.
- Reviewing existing AISH client files to ensure continued medical eligibility.
- Preparing written decisions to Albertans in accordance with the AISH Act and Regulation and AISH policy.
Completes Review of Decisions for medical and commencement date appeals by:
- Performing peer Review of Decisions for medical eligibility and commencement date determination and raising concerns to the AISH Adjudicator Team Leads when formal supervision or follow up is required.
- Reviewing initial application and medical documentation, and any other medical documentation received after the initial decision, reviewing previous decision(s) completed by peers, and determining if the initial or subsequent decision(s) is confirmed, reversed, or varied.
- Completing Review of Decisions in the Appeals Information Management System (AIMS) within 10 days of receiving an appeal. This involves preparing written documentation in accordance with the AISH Act and Regulations.
- Acting as a Department Representative at selected appeal hearings involving unusual/controversial issues.
- Determining when further consultation with the Social Enhancement Legal Team and Delivery Supports is required.
Financial Hardship Determination by:
- Reviewing the family income, monthly budget, and calculating the allowable expenses to support eligibility determination based on the level of income exemption and how often it is reviewed once approved.
- Identifying, requesting, and interpreting financial statements, investments, bills, and budgets to determine if the income reported would exceed the AISH allowable maximum.
- Providing written communication and rationale of the decision to the applicant/client and AISH Generalist.
AISH Benefits Administration Program (ABAP) by:
- Reviewing Trust Agreement documents and budgets for completion.
- Facilitating communication between AISH and key stakeholders involved in the Memorandum of Understanding.
Informal program monitoring and support to AISH Delivery Services:
- Assisting in the development of training material and delivering training on AISH medical eligibility to relevant stakeholders when needed by identifying key areas for development and drafting examples to support adult learning.
- Provide internal and external presentations to key stakeholders regarding AISH program medical eligibility, application processes and the medical review and appeals processes.
- Preparing responses or corroborating feedback to support Ministerial inquiries, action requests, telephone action requests, and other communication.
- Providing direct consultation to AISH Delivery Services staff/management in regards to the interpretation of medical eligibility criteria as required.
- Identifying application issues/processes/trends and informing the AISH Adjudicator Team Leads.
- Responding to telephone inquiries from doctors and others related to the adjudication process.
- Participating in project teams and working groups to improve program services as required.
- Participating in departmental and external meetings as required.
Reporting to the AISH Adjudicator Team Lead, this position is autonomous with minimal direct supervision within the parameters of established provincial processes, legislation, and policies. In this high volume and sensitive area, the position is primarily responsible for initial and ongoing medical eligibility decisions, determining commencement date of AISH benefits, processing appeals and additional reviews related to medical eligibility, and commencement dates.
Issues or errors related to decisions of medical eligibility may occur after the decision has been communicated to the applicant/client or the AISH Appeal panel. This emphasizes the need for peer reviews and involvement with the Team Lead to ensure accuracy, accountability, and quality assurance. The consequence of errors may impact individuals living with a permanent disability who are unable to earn a livelihood. Determining medical eligibility for the AISH program would support an improved quality of life with benefits that include a monthly living allowance, medication, a variety of personal and health benefits and employment exemptions to promote community inclusion for clients and their families. It is also noted that errors in decisions may also impact Ministerial forecasted budgets and due to the types of applications and individualized responses required, standardized decisions are not practicable. The position exemplifies decision making through interpreting complex medical and non-medical information through the adjudication process and providing timely written responses of eligibility and the rationale of decisions to applicants, clients, AISH appeal panels, internal ministry, and external staff. The work requires enhanced interpersonal communication skills to explain processes, service delivery, and eligibility decisions to Albertans in need of financial and medical supports and the community they are connected with. The position is responsive to sensitive time lines of completion and there is a need to manage the workload of initial applications to ensure they are addressed in a timely manner and the completion of Review of Decisions for Appeals are completed within 10 days. In addition, the level of effective writing skills and computer fluency is pertinent to the success in the position.
The position is responsible for the number of applications approved and responding to legislative timelines by regulating workload pressures in the number of applications, appeals, and medical reviews completed. The position also determines how contracted resources (Medical Consultants and/or Psychological Contracts) are utilized through identifying when a referral is required, the type of referral needed, and the type of assessment warranted based on the medical and nonmedical information provided. The position requires competencies achieved through research, self-directed learning, professional development, and collaborating with internal and external professionals, contracts, and identifying and communicating trends to Delivery Supports.
The position includes decision making in determining financial hardship and the AISH Benefits Administration Program. This requires basic understanding and application of relevant legislation, financial instruments, statements, transactions, legal and financial framework for financial administration of the program, (i.e. trust funds, financial statements for investments, mortgages, etc.) and collaborating within other internal and external departments.
Knowledge, Skills and Abilities
- The AISH Act and Regulations and the Applications and Appeals (Ministerial) Regulation and how this legislation applies to policy inte1prctation is essential.
- Significant understanding and/or experience with complex concurrent medical conditions and how the disability impacts the applicant's ability to earn a livelihood. This is inclusive of diagnoses in the areas of medical, psychiatric, psychological, neurological, developmental, cognitive, and addictions that are compounded by social variables.
- Understanding of treatment modalities, vocational rehabilitation approaches, and employment and training options from a disabilities perspective and how remedial therapy affects one's ability to earn a livelihood.
- Ability to interpret medical documentation (e.g. diagnostic imaging, specialist's reports, assessments, consultations, etc.) and determine when further medical or psychological consultation is required.
- Knowledge and familiarity of the types and uses of psychological assessments.
- Understanding of medical terminology, jargon, and acronyms.
- Knowledge of medications, applied diagnostic uses, and off label diagnostic uses.
- Maintaining up to date knowledge on trends and emerging medical conditions and the program's regulations and processes that support all aspects of adjudication.
- Knowledge of AISH program issues and trends with an ability to identify concerns with programing.
- Understanding of the healthcare system (Alberta and other jurisdictions).
- Working knowledge of bow other Departmental programs and outside legislation interface with AISH and impacts our client group. Includes awareness of applicable regulations, policies, and procedures within the government of Alberta.
- Working knowledge and general eligibility of other government financial programs and private insurance plans.
- Basic understanding and application of financial instruments, statements, transactions, legal and financial framework for financial administration of the program, (e.g. trust funds, financial statements for investments, mortgages, etc.).
- Strong analytical, clinical judgement and problem solving skills to review medical and non-medical documentation in conjunction with a legislated definition.
- Excellent interpersonal communication skills (verbal and written) to interact and deal effectively with internal staff, external stakeholders, applicants, clients and their representatives.
- Excellent organizational skills and command of written communication to support rationale of decisions.
- Excellent computer skills with knowledge of Word, Outlook/email, Lync, SharePoint, Excel, internal programs such as Imaging, TOI, AIMS, CCD, AISH Connects (policy) and internet. Presentations will also require the use of power point.
- Demonstrated ability to make independent decision making skills and ability to work in a high volume work environment.
- Ability to multi-task such as maneuvering through multiple IT and IM systems/programs simultaneously.
- Ability to research information on medical conditions, treatment, rehabilitation and vocational options and new treatments/and emerging technology that may modify vocational options available to applicants/clients.
- Investigative skills to determine and retrieve appropriate information regarding specific medical conditions.
- Attention to details and accuracy.
- Excellent decision making skills, writing skills, and organizational skills.
- Strong time management and analytical skills with an ability to respond to deadlines.
- Ability to interpret and examine significant amounts of medical and non-medical information and the ability to draw conclusions.
- Conflict resolution and mediation skills when dealing with differences of opinion with peers, supervisors and internal/external contacts.
- Proven ability to work as part of a team and establish effective working relationships with peers and supervisors located in various locations throughout the province.
- Presentation and training skills (AISH appeals. medical reviews, strai2htforward medical eligibility criteria, application processes, remedial therapy and earning a livelihood).
- Post-secondary education in the health related profession such as social sciences, psychology, health services, social work, community rehabilitation and disability studies is required.
- Education and experience is needed that focuses on areas such as health, treatment, intervention, vocational rehabilitation, disability management is required. In order to be successful in this position the ability to review the medical condition(s) and understand the issues and barriers related to the medical condition(s), prognosis and treatment, review non-medical information, and determine the individual's skills and limitations, identify transferable skills, and apply this information to the types of employment and modifications available as it applies to an individual's ability to earn a livelihood.
- The ability to register with a professional association in accordance with the Health Professions Act would be an asset (e.g. Registered Social Worker, Registered Nurses, Psychologists, Registered Rehabilitation Professional, Registered Vocational Professional, Registered Community Support Specialist and Occupational Therapist, etc.).
- Daily contact with AISH Adjudicator Team Lead for direct supervision, day to day needs, consultation on complex medical cases, or problem-solving.
- Participation in discussions and make recommendations relative to processes or policies affecting service delivery of the program within AISH Delivery Services.
- Daily contact with peers as previous medical eligibility decisions will be completed by peer review and if there is a difference of opinion based on the medical information presented, a change of decision may be completed.
- Regular contact with the Contracted Medical Consultants and Psychological Services to refer and review interpretation of medical data and specialized assessments.
- Regular contact with physicians, psychologist, psychiatrists and other medical experts as required for clarification on medical and non-medical information submitted.
- Daily contact with AISH Delivery Services Regional staff regarding applications and appeals processes. This includes reviewing medical assessments to determine if the standardized medical forms can be waived in lieu of a psychological assessment.
- Provide training to new staff or key stakeholders, as requested (e.g. applications, appeals, medical reviews, medical eligibility criteria, remedial therapy, and earning a livelihood).
The Government of Alberta is committed to a diverse and inclusive public service that reflects the population we serve to best meet the needs of Albertans. Consider joining a team where diversity, inclusion and innovation are valued and supported. For more information on diversity and inclusion, please visit the Diversity and Inclusion Policy.