Determines membership health insurance eligibility, establishes health insurance plan accounts, performs routine membership account adjustments, counsels enrollees on their rights, benefits, and options, and computes and processes fees for payments; or determines whether prospective enrollees meet eligibility criteria, explains account adjustments, counsels enrollees/members regarding proper course of action, and answers questions regarding health insurance benefits.

Positions in this series are found in the Health Care Authority and refer to WACs, RCWs, individual health insurance plan contract guidelines, and internal and external policies and procedures in order to counsel members, prospective members, or providers.

Explains health insurance eligibility, benefits/exclusions and premium contributions, options, services and related WACs for the various health insurance programs available through HCA and/or through coordination with other federal or state health insurance programs; 

Screens, determines health insurance eligibility; 

Enrolls health insurance applicants;  

Analyzes, explains member account adjustments; 

Makes routine adjustments to member accounts; 

Notifies members of reinstatement or termination of eligibility and/or benefits;  

Evaluates forms, certificates and other documentation for adequacy, accuracy and completeness;  

Computes premiums;  

Processes and/or generates change documents, statements and/or invoices;  

Helps to develop and distribute promotional and/or instructional material;  

Provides clients with explanation regarding enrollment forms, benefit brochures and other information material and assists clients with accurate completion of forms and processes; 

Counsels enrollees/applicants regarding proper course of action in the resolution of complaints regarding health insurance coverage and benefits; 

Verifies eligibility information to health plan representatives, completes insurance forms, and forwards to insurance carrier for final action; 

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. 

Experience providing assistance to clients/customers regarding inquiries, complaints or problems will substitute, year for year, for education. 

Each 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 will substitute for two years of education.