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State of Washington Classified Job Specification


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Class Code: 170F
Category: Financial Services


Examines and adjudicates initial system exception messages for health insurance claims.  Processes, updates, verifies and/or computes and adjusts client and/or provider eligibility, or dental authorization screens, and/or explains to clients and/or providers their benefits, rights and responsibilities.  Establishes managed care enrollment and plan accounts and performs routine account adjustments.

Distinguishing Characteristics

Positions are typically assigned the processing, correspondence, and phoning associated with the primary work in the medical assistance program.

Typical Work

Analyzes and reviews complex coded history audits and edits reference texts, control files, and master records via online MMIS; 

Determines final payment of resolutions and adjustments of turn around document(TAD) and other nursing facility claims; 

Locates, identifies, reviews, and researches original claims and their related history to assure proper adjudication of the original claim, and reimbursement; 

Verifies private insurance when client is being assigned or enrolled in Healthy Options managed care program; 

Audits reports and makes corrections to eligibility; 

Determines changes in benefits and eligibility; 

Analyzes and resolves exceptions to pharmacy point of sale claims, requiring direct contact with pharmacist; 

Responsibility for analyzing backup information for pharmacy claims and entering into system; 

Analyzes and audits pharmacy point of sale claim in order to apply benefits properly; 

Monitors computer service requests to obtain or change criteria on reports and make systems changes as necessary; 

Verifies primary care provider, clinic and plan requested; explain necessary information for clients to make informed Managed Care enrollment choices; 

Independently analyzes complex eligibility matrixes to determine enrollment availability into Managed Care; 

Independently analyzes complex records, cases and situations to timely resolve disputes related to enrollment; 

Creates written correspondence to clients; 

Coordinates multiple systems to establish eligibility and enrolls clients into Managed Care; 

Interprets programs, WACs, contracts and other matrixes to assist clients in enrollment; 

Proposes modifications, improvements and changes to procedures and policies through participation on various process improvement teams; 

Provides expert consultative services to clients, providers and plans with respect to program/plan benefits, options, and services; 

Performs other work as required.

Knowledge and Abilities

Knowledge of:  medical and dental terminology, anatomy and pharmaceuticals; State, Federal and agency rules and regulations; ICD-9-CM diagnosis and procedure codes and diagnosis-related groups. 

Ability to:  analyze medical claims and medical information for payment, determine authorization for payment and make proper determinations for processing; review and analyze medical claims for validity and compliance with rules and regulations for reporting hospital patient discharge information; prepare clear, accurate and technical correspondence; exercise tact and diplomacy; establish and maintain effective relationships with physicians, nurses, hospitals, users of the CHARS data, and others; interpret fee schedules of various localities; train and instruct hospital and agency personnel on reporting requirements; review and interpret rules and regulations and make recommendations for corrections and/or additions; communicate with hospital and the agency administrative staff verbally and in writing concerning the progress of CHARS; conduct research and identify items not conforming to standard patterns.

Legal Requirement(s)

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.

Desirable Qualifications

A Bachelor's degree.


One year of experience as a Medical Assistance Specialist 1 

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; staff support for medical assistance; 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, adds distinguishing characteristics: 3-10-78
Revised definition and minimum qualifications: 9-10-82
Revised definition: 9-11-87
Revised definition, distinguishing characteristics, minimum qualifications, general revision, code change (formerly 4701), title change (formerly Medical Claims Examiner 1): 6-9-89
Revised definition: 6-15-90
Revised definition, distinguishing characteristics and minimum qualifications; title change (formerly Medical Claims Examiner 2): 11-19-98
New class code: (formerly 46350) effective July 1, 2007