Medical Insurance Specialist (U) (4583)

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This person will serve as a lead worker of Medical Insurance staff, orientate new staff, and serve as a resource to all staff, residents, physicians and nurses in the Department of Surgery. This person will be responsible for the pre-authorizations/pre-certifications of patient procedures for the Department of Surgery. This position will be responsible for assisting with maintaining a departmental managed care manual as well as updating faculty and staff within the department of changes in the managed care process. This person will interact with physicians, nurses and supportive staff within the Department of Surgery, as well as insurance companies, patients and outside facilities.

Preauthorization / Precertification: 75%
A. Verifies accuracy of billing codes for ALL medical procedures related to the processing of pre-authorizations and pre-determinations. Ensures planned services are appropriately preauthorized/precertified to secure the accurate billing process of patient procedures (e.g. diagnostic tests, inpatient and outpatient surgeries, rehab, DME). This involves discussion with the physician or nurse, reviewing patient's medical record for necessary documentation and disseminating the appropriate information to the managed care/insurance company in order to secure approval of the patient procedure(s).
B. Provide faculty and staff with updated regarding changes made to managed care/insurance procedures and protocols.
C. Maintain a central resource manual of managed care/insurance plans.
D. Respond to inquiries from physicians, nurses, hospitals, government agencies, insurance companies, managed care companies and patients concerning requests for assistance to ensure appropriate coverage for planned medical services.
E. Receive and respond to patient calls regarding insurance questions, precerts, authorizations, billing issues, etc.
F. Identifies, analysis and takes necessary action in the review of insurance denials in order to determine appropriate course of action required to accurately complete the medical review process for appeal and resolution.
G. Secure additional health information from the patient and/or physician regarding the episode of care being denied and initiate follow up discussions with insurance organizations in order to obtain medical review.
H. Correspond with physicians, nurses, hospitals, government agencies, insurance companies, managed care companies and patients as required to identify and collect the information required to complete authorization process.
I. Obtain standard, established codes acquired from ICD-10 and CPT code books after chart review and or discussion with physician or nurse and disseminate to the certifying agency.
J. Maintain accurate record of preauthorization./predetermination through entering appropriate information in the computerized data systems
K. Create computer precertification forms to make process more efficient.

Administrative: 20%
A. Attend training session, meeting and conferences and read publications to remain current on the policies and procedures of managed care/ insurance companies.
B. Serve as a Lead Medical Insurance Specialist in the Department of Surgery, being one of the main contact persons for lower level specialists in the department, physicians, nurses, and staff as well as outside facilities to handle any
problems that may arise with regards to lower level insurance staff, complex procedures, etc.
C. Assist in the training and evaluating of new and lower level Medical Insurance staff I the Department of Surgery
D. Maintain and assist in updating procedure manuals for all Medical Insurance staff within the department. This position will assist in monitoring workflow and making distribution adjustments accordingly, when appropriate.
E. Participate in SIU Physician & Surgeons committees as requested.

5%
Performs other duties as required or assigned which are reasonably within the scope of the duties described above.

Credentials to be Verified by Placement Officer

1. Any one or combination totaling two (2) years (24 months), from the categories below:
   1. College coursework in a health-related field, business administration/management, human resource management, or closely related fields, as measured by the following conversion table or its proportional equivalent:
      • 30 semester hours equals one (1) year (12 months)
      • Associate's Degree (60 semester hours) equals eighteen months (18 months)
      • 90 semester hours equals two (2) years (24 months)
   2. Work experience in a healthcare environment working independently with medical claims, denials, rejections, referrals, and prior authorizations.

1. Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluating customer satisfaction.
2. Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
3. Knowledge of complex medical terminology, hospital or physician billing and coding, referrals, and prior authorizations.
4. Knowledge of arithmetic with the ability to add, subtract, multiply and divide whole numbers, decimals and percentages.
5. Skill in evaluating information to determine compliance with standards. Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, standards and ensuring that lower-level employees are following standards.
6. Skill in using computers and computer systems (including hardware and software) to program, write, set up functions, enter data, or process information.
7. Ability to pay close attention to details, follow established procedures to complete work tasks and train others in those procedures.
8. Ability to maintain patient confidentiality following HIPAA guidelines and established policies and procedures.
9. Ability to train others and work collaboratively, building strategic relations with colleagues, coworkers, constituents.
10. Ability to plan, assign, and supervise the work of others.

Condition of Employment

Pursuant to the State Universities Civil Service System, an out-of-state resident who is hired into this position must establish Illinois residency within 180 calendar days of their start date.

If you require assistance, please contact the Office of Human Resources at hrrecruitment@siumed.edu or call 217-545-0223 Monday through Friday, 8:00am-4:30pm.

The mission of Southern Illinois University School of Medicine is to optimize the health of the people of central and southern Illinois through education, patient care, research and service to the community.

The SIU School of Medicine Annual Security Report is available online at https://www.siumed.edu/police-security. This report contains policy statements and crime statistics for Southern Illinois University School of Medicine in Springfield, IL. This report is published in compliance with Federal Law titled the

"Jeanne Clery Disclosure of Campus Security Policy and Crime Statistics Act."

Southern Illinois University School of Medicine is an Affirmative Action/Equal Opportunity employer who provides equal employment and educational opportunities for all qualified persons without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, protected veteran status or marital status in accordance with local, state and federal law.

Pre-employment background screenings required.