See Medical Assistance Specialist 1.

Provides senior level consultation and adjudication of medical, dental, vision and behavioral health insurance benefits and services to providers, clients, members and stakeholders. Determines prior authorizations for medical and dental services; coordination of benefits; adjudication of complex claims; resolves technical problems, complex eligibility, enrollment or claims issues.

This is the senior level of the series. Positions independently perform professional and technical duties related to complex state and federal medical insurance benefits programs, systems and services. Positions at this level may be distinguished from the Medical Assistance Specialist 2 by their independence of action, limited supervisory direction and broad discretion to perform the full range of technical and professional duties.

Assists client and member in managing and navigating their online electronic profiles and benefits elections;

Serves as primary contact for client, member and provider in determining initial or ongoing eligibility for Medicaid/Washington Apple Health; conducts post-enrollment reviews; resolves client eligibility issues; calculates Medicaid Adjusted Gross Income based on client financial information;

Serves as a liaison with the Department of Retirement Systems, employers and provider to coordinate eligibility information, answers questions and resolves issues; determines medical insurance eligibility benefits for retirees;

Processes applications and documents, reviews enrollment forms, Medicare cards, dependent verification, tobacco and spousal premium surcharges and wellness incentives;

Coordinates premium payments to managed care health plans; processes recoupments and recoveries of premiums and overpayments; coordinates benefits to ensure primary and secondary coverage for Medicaid clients;

Researches, analyzes and determines payment/denial of complex medical claims; approves services requiring authorization;

Monitors monies in order to comply with payment policies and regulations; adjudicates cash receipts for processing of refunds and program payments;

Approves services requiring prior authorization based on diagnosis codes, treatment plans and provider documentation;

Approves vendor registration and payments; maintains computer vendor files for accuracy and resolution of discrepancies;

Resolves transportation and interpreter issues;

Consults with provider staff regarding multiple programs and complex systems related to billing processes;

Approves revalidations, updates and activities for qualified providers; identifies providers out-of-compliance with Medicaid eligibility requirements;

Performs the duties of the lower levels in the series;

Performs other work as required.

Knowledge of: complex state and federal medical assistance laws, rules regulations and service programs; health plan benefits; medical terminology, anatomy and pharmaceuticals; standards of medical treatment and practice; social and economic conditions and their effects on individuals; fundamentals of customer service and person-to-person communication.

Ability to: make independent conclusions and decisions; review and authorize complex medical claims for payment; determine benefit eligibility and enrollment; analyze medical and accident information and make proper determinations; calculate household income; establish and maintain effective working relationships with clients, members, providers and stakeholders; prepare clear and accurate correspondence; accurately document, listen, observe, communicate, confront and engage in problem solving and conflict resolution; interpret fee schedules; process documents and make medical policy decisions through complex integrated 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.

A Bachelor's degree


One year 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/eligibility related experience; or experience researching and analyzing complex rules, regulations and policies to make determinations and resolve problems while providing direct customer service.


One year as a Medical Assistance Specialist 2.

Additional experience may substitute, year for year, for the required education.

Completion of the Certificate of Medical Billing and Coding or related certificate may substitute for up to two years of education.

New class: 5-1-68.
Revised definition and minimum qualifications; adds distinguishing characteristics: 3-10-78.
Revised definition and distinguishing characteristics: 6-15-79.
Revised definition and distinguishing characteristics: 9-10-82.
Revised definition and distinguishing characteristics: 1-13-84.
Revised definition, minimum qualifications, and general revisions. Deletes distinguishing characteristics. Revises code (formerly 4702) and title (formerly Medical Claims Examiner 2): 6-9-89.
Revised definition, distinguishing characteristics and minimum qualifications; title change (formerly Medical Claims Examiner 3): 11-19-98.
New class code: (formerly 46360) 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.