State of Washington Classified Job Specification
ES BENEFITS SPECIALIST 1
Class Series Concept
See ES Benefits Technician.
This is the entry level of the series. Positions perform basic and routine professional duties related to insurance benefits programs and services.
Working under direct or close supervision positions develop a working knowledge of first-level professional insurance benefits determination assignments, including processing basic and routine claims, conducting interviews, reviewing applications and documents to determine initial eligibility, perform basic adjudication and collects taxes and premiums from employers.
Adjudication at this level is distinguished from the higher levels by the absence of research and analysis.
Tasks are recurring and limited in scope. Assignments require basic analysis of a variety of applicable state and federal laws, regulations and policies. Scope of work is within established program standards.
Assists employers in the use of electronic filing and payment methods;
Assist claimants in filing basic insurance benefits claims;
Explains appeal rights and applicable laws and policies;
Interviews claimants/customers, analyzes written and oral information, and determines eligibility for benefits; assesses claimant/customer immediate need in emergent situations; implements case closures per compliance regulations, policies, and changes in claimants eligibility;
Obtains and reviews necessary data, such as employer premium/wage reports;
Explains program requirements and services available;
Refers claimant/customer to both mandatory and optional services and to other agencies as required;
Resolves routine claimant/customer problems by identifying the issues, determining procedural steps necessary to bring resolution, working with program staff to implement resolution, and communicating results to the claimant/customer;
Calculates, prepares and reviews routine tax and wage reports to determine completeness and accuracy;
Audits the out-of-balance report by analyzing total wages on system to the total wages on tax report;
Reads and interprets Washington Administrative Codes and procedural manuals;
Registers new businesses, utilizing an automated system; updates information on businesses already on the automated system;
Makes changes and updates information in claimants and employer accounts to ensure accuracy; creates and manages claimants and employer profiles and maintains integrity of the data and information while delivering program services;
Collects taxes and premiums from employers;
Processes and adjudicates routine claims;
Detects discrepancies and clarifies data through telephonic and electronic inquiries, correspondence, and interviews; recognizes and re-calculates incorrect payments of benefits and established overpayments;
Reviews initial claims for program benefits; determines the need to obtain additional employment or medical documentation or supporting evidence from employers, medical and non-medical providers;
Prepares written correspondence to medical and non-medical providers of information and conducts telephonic interviews with these providers when necessary;
Performs the duties of the lower levels in the series;
Performs other duties as required.
Knowledge and Abilities
Knowledge of: insurance benefits service programs, applicable state and federal laws, regulations and policies, principles, problems, and practices of insurance benefits programs; theory and practices of accounting and auditing; principles of individual and group behavior, social behavior, social and economic conditions, and their effects upon individuals office procedures and practices.
Ability to: make independent conclusions and decisions; evaluate and recommend changes to insurance benefits program management; work cooperatively with staff, members of the public and with co-workers; practice tact, courtesy and discretion; accurately document, listen, observe, communicate, confront and engage in problem solving and conflict resolution; convey interest and concern to claimants requesting information or assistance with problems related to insurance benefits programs and services; analyze accounts and accounting records; prepare accounting and legal documents; perform routine accounting procedures.
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 in a health or social science, public administration or a related field.
Four years of experience examining and/or processing loan applications, medical insurance or rehabilitation claims, insurance claims, collection of insurance premiums, tax collection or providing staff support in financial eligibility determination.
A combination of education and relevant experience.
Class Specification History
New class adopted 5/17/2018, effective 5/18/2018.
Revised title, definition, distinguishing characteristics, typical work, knowledge and abilities, adopted June 22, 2023, effective July 1, 2023.