See Medical Assistance Specialist 1.

Processes, updates, verifies and/or adjusts clients, members and/or provider eligibility, enrollment or authorization services, and/or explains benefits, rights and responsibilities. Performs routine account adjustments, eligibility determinations, enrollment, changes in circumstances and case actions.

This is the journey level of the series. Positions perform routine assignments following established procedures, formats and priorities.

Reviews, researches, analyzes and adjudicates routine changes in circumstances to determine ongoing eligibility for client, member and provider within program requirements using multiple computer systems;

Evaluates financial records, documentation, data and systems to continue or terminate coverage based on program requirements;

Analyzes and reviews coded history audits and edits reference texts, control files, and master records via an online Medicaid Management Information System;

Determines final payment of resolutions and adjustments of turn around document 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 a managed care program;

Implements program changes and case closures as directed by regulations, policies and changes in circumstances;

Analyzes backup information for pharmacy claims and enter into computer system;

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

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

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

Reads and interprets Washington Administrative Code, procedural manuals, contracts and other matrixes to assist clients in enrollment and services available;

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

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

Resolves routine client, member and provider problems, identifies issue, determines steps for resolution, works with program staff to implement and communicates results to client, member and provider;

Performs the duties of the lower levels in the series;

Performs other work as required.

Knowledge of: office practices and procedures; medical and dental terminology, anatomy and pharmaceuticals; research and analysis methodologies; 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; calculate basic financial eligibility based on program requirements; 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 stakeholders; interpret fee schedules; review and interpret rules and regulations and make recommendations for corrections and/or additions; 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 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; or experience researching and analyzing complex rules, regulations and policies to make determinations and resolve problems while providing direct customer service in person, by telephone or via computer will substitute, year for year, for the required education.

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.
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.