Performs the full range of professional health insurance benefits advisory duties; performs credentialing/recredentialing under the Uniform Medical Plan, or leads Health Insurance Benefits Specialists 1.

Positions in this class fit into one of the following categories:  (1) performs the full range of professional health insurance benefits advisory duties which includes but is not limited to researching and resolving health insurance issues, performing complex account adjustments such as plan changes, retroactive and manual enrollments, and premium adjustments; (2) designated lead of three or more Health Insurance Benefits Specialists 1 by regularly assigning, instructing and checking their work and performing of the duties of the Health Insurance Benefits Specialist 1; or, (3) determines which health care providers should receive credentialing/recredentialing under the Uniform Medical Plan.

Performs skilled work which includes, but exceeds in scope, those duties typically performed by a Health Insurance Benefits Specialist 1; 

Analyzes, negotiates and resolves complex health insurance issues and/or technical problems involving WACs, RCWs, rules, laws, agencies, carriers, providers, membership, beneficiaries or others; 

Provides expert consultative services to members, beneficiaries, and/or others with respect to health program/plan benefits, options and services; 

Audits and makes complex membership account adjustments; 

Utilizing knowledge of contracts and related material, independently determines which providers meet the plan’s credentialing requirements, which need Medical Director review, and which applicants to reject; 

Researches and presents findings to Medical Director and quality assurance committee for determination of preferred provider status; 

Coordinates enrollee’s health insurance eligibility and managed health care enrollment with other state agency programs; 

Develops modifications, improvements and changes to procedures and policies; 

Makes oral presentations, participates in promotional events and/or provides orientation and education to providers or others regarding policies and procedures and/or program participation; 

Acts as a lead worker for lower level health insurance benefits specialists; 

Performs other work as required.

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 and one year of experience providing direct client services or counseling of customers in the areas of deferred compensation, health insurance, retirement, unemployment, disability, or other related employee benefits programs. 

Additional years of experience will substitute, year for year, for education.

OR 

One year as a Health Insurance Benefits Specialist 1 or Customer Services Specialist 2 within the Health Care Authority. 

OR 

Two years as a Benefits Specialist 1.