Definition

Examines, adjudicates and/or adjusts routine health insurance claims, enrollment forms or requests for authorization of services.  These functions are performed in response to system edits, standard codified policy statements or operating policies and procedures.

Distinguishing Characteristics

This is the entry level class within the series. Positions at this level utilize a limited range of system capabilities dealing with the internal consistency of the claim, eligibility of the recipient and health care provider, and validity of claim, etc.

Typical Work

Analyzes medical and dental claims for appropriateness of payment/denial; 

Deciphers and interprets written information submitted by providers and health plans; 

Assists providers with eligibility issues; 

Reviews, audits and authorizes payment /denial of medical claims; 

Researches billing discrepancies; 

Reconciles client eligibility in multiple mainframe environments for “Qualified Medicare Beneficiary” (QMB), “Special Low-Income Medicare Beneficiary” (SLMB), and “Qualified Disabled Working Individuals” (QDWI) programs; 

Analyzes and recommends to supervisor whether the State should pay Part A Medicare premiums or not;  

Analyzes data on multiple information systems to determine Part A and/or Part B Medicare buy-in premium eligibility; 

Responsible for adding and correcting Medicare information to multiple eligibility databases in order to assure correct payment of Part A and/or Part B Medicare buy-in premiums; 

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; prepare clear, accurate and technical correspondence; exercise tact and diplomacy; establish and maintain effective relationships with physicians, nurses, hospitals, and others; review and interpret rules and regulations and make recommendations for corrections and/or additions.

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

High school graduation or GED. 

AND 

One year of experience in public assistance eligibility determination; health insurance claims processing, adjusting, investigation; providing staff support in medical assistance; or other closely related experience.  

One year of college will substitute for the one year of required experience.

Class Specification History

New class: 6-9-89
Revise definition, distinguishing characteristics and minimum qualifications; title change (formerly Medical Claims Examiner 1): 11-19-98
New class code: (formerly 46340) effective July 1, 2007