State of Washington Classified Job Specification
MEDICAL ASSISTANCE SPECIALIST 4
Class Series Concept
See Medical Assistance Specialist 1.
Serves as a designated lead worker over lower level staff which must include at least one MAS3; or provides formal training, guidance and expertise to staff, providers and stakeholders to ensure uniform application of program rules, policies and regulations; or serves as a quality assurance reviewer of the work performed by lower level staff; or serves as an expert analyzing workflow and automated systems problems, devises and implements new and revised procedures and monitors ongoing systems operations to ensure accurate coding, compliance with program requirements and complex regulations, adjudicating payments and recoupments.
Provides guidance to lower level staff interpreting a broad range of systems edits and audits to resolve complex enrollment, eligibility, claims and payment determinations; monitors system for errors, corrects discrepancies, resolves error codes and system workflow issues;
Reviews and researches complex enrollment and eligibility issues identified by lower level staff; makes recommendations for appropriate action;
Develops and implements new and revised procedures and monitors ongoing systems operations and related activities;
Interprets and explains the most complex policies and regulations to lower level staff processing eligibility reviews or determining ongoing medical eligibility;
Researches and analyzes complex claims for accuracy, completeness, rebating invoicing, recoupment and recoveries; initiates corrections or adjustments;
Assigns and audits work of staff; identifies training needs, reviews cases for accuracy;
Plans payment of billings from medical providers and hospitals for medical benefit recipients;
Assists staff in determining final disposition of complex billings; instructs staff in use of tact and diplomacy;
Consults with unit and supervisor on policies and procedures, problem solving, workflows, and public relations;
Meets with medical providers to resolve problems and with medical staff on development of program policy;
Aids in the development and implementation of medical policy and pricing controls in the Medicaid Management Information System;
Coordinates with trainers for staff mentoring and on-boarding;
Assist client and members in resolving log in issues;
Designs, develops and updates lesson plans, handbooks, assessments, handouts, trainer guides and training materials;
Provides support, guidance and training for staff, providers and employers on program policies, rules, regulations and procedures;
Identifies training requirements and develops training plans;
Creates billing instruction for providers;
Advises and assists managers in planning and conducting local training programs; develops recommendations on training needs, assessments and issues;
Develops, schedules and conducts training on new policies, procedures, state regulations and requirements for program eligibility and service delivery;
Examines and access claims for accuracy, completeness, rebating invoicing, recoupment and recoveries and benefits administration actions;
Identifies error trends and determines training needs;
Analyzes workflows and automated systems to identify problems requiring correction;
Monitors the ongoing activity of clients, members, providers and beneficiaries that have been identified as deviating from pre-described norms of practice;
Correlates input obtained from outside sources into case files to begin building history on specific providers;
Uses reports from a Medicaid Management Systems to monitor workflows and ensure claims are processed accurately and efficiently;
Identifies instances of client, member, provider or beneficiary over-utilization and refers them to the appropriate agency for review;
Reviews and validates post-eligibility reviews completed by lower level staff;
Performs the duties of the lower levels in the series;
Performs other work as required
Knowledge and Abilities
Knowledge of: complex state and federal medical assistance laws, rules, regulations and service programs; health plan benefits; medical terminology, anatomy and pharmaceuticals; principles of employee development, principles of individual and group behavior, social behavior, social and economic conditions and their effect on individuals; effective lead and supervisory skills and public relations.
Ability to: plan, supervise and direct organization composed of related units; make valid decisions on complex medical billings, inquiries and/or policy matters; use tact and diplomacy in handling correspondence or in direct contact with stakeholders; establish and maintain effective relationships with physicians, hospitals and other authorized vendors; make independent decisions; supervise and train staff.
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.
Two 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 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: 10-1-76
Revised definition and minimum qualifications: 3-10-76
Revised definition: 6-15-79
Revised definition: 9-10-82
Revised minimum qualifications: 11-14-83
Revised definition: 1-13-84
Revised definition and minimum qualifications, and adds distinguishing characteristics. Revise code (formerly 4703) and title (formerly Medical Claims Examiner 3): 6-9-89
Revised definition: 9-14-90
Revised definition, distinguishing characteristics and minimum qualifications; title change (formerly Medical Claims Examiner 4): 11-19-98
New class code: (formerly 46370) effective July 1, 2007.
Added class series concept, revised definition, distinguishing characteristics, typical work, knowledge and abilities, desirable qualifications, salary range adjustment, adopted June 22, 2023, effective July 1, 2023.