This series is responsible for providing medical eligibility determinations, enrollment, guidance and adjudication of medical insurance benefits to clients, members, providers and stakeholders. Positions investigate, research and analyze financial records, information, data, systems, program policies, procedures and benefits. Positions determine financial and program eligibility, prior authorizations, adjudicate claims, and coordinate and administer benefits.

Reviews, researches, analyzes and interviews clients to determine or re-determine eligibility for medical insurance benefits. Processes changes in clients circumstances and determines continuing eligibility of clients and providers.

This is the entry level of the series. Positions utilize a limited range of system capabilities dealing with the eligibility of the client and/or health care provider and the validity of claim within program requirements.

Reviews, researches, analyzes and adjudicates changes in client circumstances to determine or re-determine client eligibility within program requirements using multiple computer systems; terminates client coverage;

Explains program requirements, policies, procedures, benefits and rights and responsibilities in accordance with state and federal requirements;

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

Deciphers and interprets written information submitted by clients, members, providers and health plans;

Assists providers with eligibility issues;

Researches billing discrepancies;

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

Performs other work as required.

Knowledge of: office practices and procedures; business English and letter writing; research and analysis methodologies; medical and dental terminology; State, Federal and agency rules and regulations; and Health Insurance Portability and Accountability Act.

Ability to: develop interviewing skills; learn to interpret and analyze data within established procedures; learn complex computer systems; review and analyze medical claims for validity and compliance with rules and regulations; prepare clear, accurate and technical correspondence; exercise tact and diplomacy; review and interpret rules and regulations and make recommendations for corrections and/or additions.

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.

Associate’s degree.


Two years of experience examining and processing medical, rehabilitation or unemployment insurance claims or public benefits eligibility determination; providing direct customer support; providing staff support in benefits eligibility and determination; researching, interpreting and communicating complex rules, regulations and requirements.

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

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.
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.