Supervises a unit of Medical Assistance Specialists who provide medical insurance eligibility, determination, enrollment and adjudication of benefits and claims. Establishes and implements unit workloads, standards, processes and procedures. Provides leadership, guidance, mentoring, support and on-going feedback to staff; conducts performance evaluations.

Plans, develops, implements, monitors and supervises activities of staff who review provider applications, modifications, enrollment correspondence and activities related to the Affordable Care Act including revalidations, fingerprint based criminal background checks, site visits, application fees and database checks; and allow or reject medical billing claims;

Participates in developing program policy with medical provider groups, legislative and Federal representatives; develops and maintains application of policy, pricing controls and eligibility in the computer system;

Explains policies and rules to unit specialist; works with stakeholders on procedural and system development;

Makes decisions regarding staffing levels; interviews and hires applicants; initiates and directs training for Medical Assistance Specialists; evaluates performance and recommends placements and reassignments;

Analyzes statistical reports; reviews activity reports to ensure planned unit volume levels are being maintained and work is processed within established timeframes;

Establishes unit workloads and quality standards; reviews completed authorization requests, complaints and eligibility determinations to ensure data gathering and findings are accurately documented;

Consults with agency management regarding unit budget requirements for staffing, equipment, space, etc.

Makes recommendations regarding revised systems and procedures to accommodate program changes and improvements;

Performs the duties of the lower levels in the series;

Performs other duties as required.

Knowledge of: complex state and federal medical assistance laws, rules, regulations and service programs, health plan benefits; medical and dental terminology, anatomy and pharmaceuticals; principles of employee development, effective supervision and public relations; principles of individual and group behavior, social behavior, social and economic conditions and their effect on individuals; principles of administration, personnel management and organization; effective supervisory skills.

Ability to: plan, supervise and direct organization composed of related units; make valid decisions regarding complex medical billings, inquiries and policy matters; use tact and diplomacy in correspondence or direct contacts with stakeholders; conduct staff meetings, train and instruct others; evaluate performance and develop employee potential; convert State of Washington policies and procedures to the Medicaid Management Information System and other programs’ systems.

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.

Persons legally authorized to work in the U.S. under federal law, including Deferred Action for Childhood Arrivals recipients, are eligible for employment unless prohibited by other state or federal law.

A Bachelor's degree and four years of 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; health insurance premiums/claims processing, adjusting, and investigation; or other medical premiums/claims related experience.

OR

One year as a Medical Assistance Specialist 4.

OR

Two years as a Medical Assistance Specialist 3.

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; health insurance premiums/claims processing, adjusting, and investigation; or other medical premiums/claims related experience will substitute, year for year, for the required education.

Revises code (formerly 4704) and title (formerly Medical Claims Examiner 4): 6-9-89.

Revised definition, distinguishing characteristics and minimum qualifications; title change (formerly Medical Claims Examiner 5): 11-19-98.
New class code: (formerly 46380) 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.

Revised Legal Requirements; effective June 6, 2024, due to adopted legislative action.