State of Washington Classified Job Specification
MEDICAL ASSISTANCE SPECIALIST 3
Provides expert consultative services to providers, clients, and/or other external customers and independently:
- Determines prior authorization of medical services; or
- Adjudicates complex claims utilizing multiple systems and/or contracts; or
- Coordinates benefits; or
- Interprets, coordinates and/or services complex medical accounts such as exemptions from managed care enrollment and complaint resolution and/or enrollments such as those involving the Basic Health Plan; or
- Determines initial and/or ongoing medical eligibility for medical assistance programs; or
- Resolves technical problems involving clients, agencies, carriers, and/or providers; or
- Trains newly hired entry level internal staff; or
- Supervises a unit of Medical Assistance Specialists 1s and/or 2s.
Positions are assigned investigation, research, and analysis duties involved in resolving problems such as payments to providers, eligibility, enrollment, recoupment, overpayments, and authorizations a majority of the time. Positions at this level may be distinguished from the Medical Assistance Specialist 2 by their independence of action, limited supervisory direction, and broad discretion to perform the full range of technical and professional duties.
Supervises lower level staff;
Coordinates premium payments to managed care health plans; coordinates managed care, fee for service and other agency coverage and benefits for Medicaid clients;
Researches and resolves conflicting eligibility information;
Recoups and/or adjusts health care premium payments;
Coordinates processing interactions between managed care and fee for service;
Implements policies and procedures;
Provides expert consultation on health care plans, eligibility and technical implications of coordination;
Researches, analyzes and determines payment/denial of most complex medical claims; approves services requiring authorization;
Monitors monies in order to comply with payment policies and regulations;
Resolves complex complaints, problems and conflicts;
Trains lower level and new staff;
Approves vendor registration and payments;
Maintains computer vendor files for accuracy and resolution of discrepancies;
Researches and coordinates managed care health plans;
Resolves transportation and interpreter issues;
Determines client eligibility via telephone application and direct interview; coordinates health plans with Washington State Health Care Authority;
Researches, analyzes and administers fair hearings;
Determines recoupment of Healthy Options premiums; primary and secondary coverage for Medicaid clients;
Assists provider staff regarding pharmacy point of sale billing process;
Performs other work as required.
Knowledge and Abilities
Knowledge of: State and Federal and departmental rules and regulations, medical and dental terminology, anatomy and pharmaceuticals; standards of medical treatment and practice.
Ability to: review and authorize complex medical claims for payment; analyze medical and accident information and make proper determinations; establish and maintain effective working relationships with hospitals, physicians and other authorized medical providers; prepare clear, accurate and technical correspondence; interpret fee schedules; train and instruct others; process documents and make medical policy decisions through the Medicaid Management Information System; review and interpret rules and policy directives; conduct research and identify items not conforming to standard patterns.
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
one year 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 2.
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
New class: 5-1-68
Revised definition and minimum qualifications; adds distinguishing characteristics: 3-10-78
Revised definition and distinguishing characteristics: 6-15-79
Revised definition and distinguishing characteristics: 9-10-82
Revised definition and distinguishing characteristics: 1-13-84
Revised definition, minimum qualifications, and general revisions. Deletes distinguishing characteristics. Revises code (formerly 4702) and title (formerly Medical Claims Examiner 2): 6-9-89
Revised definition, distinguishing characteristics and minimum qualifications; title change (formerly Medical Claims Examiner 3): 11-19-98
New class code: (formerly 46360) effective July 1, 2007