State of Washington Classified Job Specification
MEDICAL ASSISTANCE SPECIALIST 5
Supervises a unit which must include a technical Medical Assistance Specialist 3 or Medical Assistance Specialist 4.
Plans, develops, administers, coordinates and/or supervises activities of examiners and clerical personnel in receiving and indexing claims, claims review and allowance or rejection of claims;
Assists in developing program policy through attendance at medical staff meetings and conferences with various provider groups, legislative and Federal representatives; develops and maintains application of policy and pricing controls and provider eligibility in the computer system;
Directs analysis and review of computer-generated utilization review documents;
Defines specific criteria to be used in detecting and interpreting trends and patterns of Medicaid practice reflected on the utilization and review reports;
Interviews and hires applicants; initiates and directs in-service training programs for Medical Assistance Specialists; analyzes statistical reports;
Maintains good working relationships through coordination with all medical provider groups;
Performs other work as required.
Knowledge and Abilities
Knowledge of: department, State and Federal rules and regulations, medical and dental terminology, anatomy and pharmaceuticals; principles of employee development, effective supervision and public relations; basic principles of administration, personnel management and organization; data processing.
Ability to: plan, supervise and direct organization composed of related units; make valid decisions regarding complex medical billings, inquiries and policy matters; use tact and diplomacy in correspondence or direct contacts with professional medical personnel; establish and maintain effective relationships with physicians, hospitals and other authorized providers; conduct staff meetings, train and instruct others; evaluate performance and develop employee potential; convert state of Washington policies and procedures to the Medicaid Management Information System.
There may be instances where individual positions must have additional licenses or certification. It is the employer’s responsibility to ensure the appropriate licenses/certifications are obtained for each position.
A Bachelor's degree
four years of experience providing direct client services or counseling of customers in the areas of health insurance, disability, or other related health benefits; public assistance eligibility determination; health insurance premiums/claims processing, adjusting, and investigation; or other medical premiums/claims related experience.
One year as a Medical Assistance Specialist 4.
Two years as a Medical Assistance Specialist 3.
Experience providing direct client services or counseling of customers in the areas of health insurance, disability, or other related health benefits; public assistance eligibility determination; health insurance premiums/claims processing, adjusting, and investigation; or other medical premiums/claims related experience will substitute, year for year, for the required education.
Class Specification History
Revised minimum qualifications: 3-8-71
Revised definition and minimum qualifications; adds distinguishing characteristics: 3-10-78
Revised definition and distinguishing characteristics: 9-10-82
Revised minimum qualifications: 11-14-83
Revised definition and distinguishing characteristics: 3-3-86
Revises definition and minimum qualifications, and deletes distinguishing characteristics.
Revises code (formerly 4704) and title (formerly Medical Claims Examiner 4): 6-9-89
Revised definition, distinguishing characteristics and minimum qualifications; title change (formerly Medical Claims Examiner 5): 11-19-98
New class code: (formerly 46380) effective July 1, 2007