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Health Care Billing Compliance Auditor

July 27 2020
Categories Accounting, Finance, Health, Medical, Billing, Other Health Professionals, Medical records
Toronto, ON

The Workplace Safety and Insurance Board (WSIB) helps people overcome workplace injuries and illnesses and helps business owners make their workplaces safe and healthy. Our people are at the heart of what we do. Bring your enthusiasm and expertise to the WSIB, and we'll help you achieve your personal and professional goals through meaningful work, development opportunities and a culture of compassion, integrity and teamwork.

We are the WSIB. And we're here to help. 

WSIB offices remain closed due to COVID-19. Our priority is the health and wellness of employees and the people of Ontario. As such, this position may involve working from home for all or part of the duration of this position.

Job Summary:

Perform health care billing compliance audits and reviews by conducting comprehensive claim file reviews, and health care billing analysis to validate health care supplier and provider billing submissions and payments are compliant with WSIB expectations, policies, guidelines and legislation. Provide compliance related education to stakeholders. Identify health care billing compliance trends and anomalies, potential fraud and non-compliance, and make risk based recommendations to Senior Management. Lead Confirmation of Services outreach initiatives, collecting and analyzing information directly from external stakeholders.

Major Duties & Responsibilities:

1. Act as a subject matter expert and resource related to health care billing compliance by:

  • Identifying and participating in outreach opportunities to internal and external stakeholders to provide educational information on policies, legislation, processes and billing practices.
  • Providing insight and feedback on health care billing to the Specialized Provider Compliance Team
  • Providing insight and feedback into the creation and improvements of risk models used to proactively identify health care billing compliance risks
  • Participating in cross cluster projects/initiatives
  • Researching analyzing and providing recommendations related to complex health care billing compliance issues presented by internal and external stakeholders

2. Research, develop, evaluate and provide feedback on new and existing health care billing educational materials for both internal and external stakeholders.

3. Conduct audits and reviews of health professionals WSIB billings and practices to monitor provider compliance with policy, legislative requirements (including WSIA, Criminal Code, Health Insurance Act etc..), administrative practice expectations, billing processes and fee schedules/ This includes:

  • Making recommendations that could include outreach/education, recovery of payment for inaccurate billings, revoking billing privileges, improvements to risk related tools and investigation/prosecution
  • Identifying dependencies on data elements and identifying false/positive data results
  • Contacting internal and external stakeholders to provide education, for clarification or to probe for additional information
  • WSIB claim reviews
    Researching and interpreting relevant legislation
  • Analyzing the results
  • Identifying compliance related anomalies and patterns
  • Preparing summary reports and presentation materials for Senior Management
  • Presenting findings to Senior Management

4.  Conducting joint healthcare billing audit reviews with other Ministries, agencies, professional collegse, or other billing service providers by:

  • Conducting detailed claim reviews in comparison to the insured services health care billings. This requires the knowledge and application of case management/adjudication principles and processes to determine the appropriateness of the payment of the physician services;
  • Interpreting the MOHLTC / WSIB Agreement and Highway Traffic Act to determine if WSIB claims were accurately coded as Motor Vehicle Accidents for the purposes of health care payments
  • Analyzing and providing results of the audit to assist in determining the payment adjustment factor;
  • Contributing to the scope and protocols developed prior to each audit including, Terms of Reference requirements processes for review, reporting conventions, acceptable claim populations, sample sizes, and rules of analysis

5. Conduct Confirmation of Services initiatives related to health care billing compliance by:

  • Providing education on initiatives and health care billing compliance
  • Corresponding verbally and in writing with external stakeholders
  • Probing for new information, clarifying existing  information, actively listening, and documenting findings
  • Referring external stakeholders to the appropriate area of the WSIB for additional assistance outside the scope of health care billing compliance
  • Verifying if health care related services / products were received and necessary
  • Verifying if health care related billings / payments were accurate

6. Develop health care billing compliance audit  processes, guidance documents, training and presentation materials. Provide training and educational presentations to new hires and internal partners related to health care billing compliance.

7. Other related duties as assigned or required.

Job Requirements:


  • University completion at undergraduate level.


  • Total of ten years and seven months experience.  Seven years prior experience in case management.  Three years and seven months experience on the job to reach full working level.

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. network