Medical Insurance Specialist (U) (4583)

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This person will be responsible for the preauthorization / precertification of patient medications for the Department of Otolaryngology. This person will assist in maintaining a Departmental managed care manual as well as updating faculty and staff in the Department regarding changes in the managed care process. This person will interact with physicians, residents, nurses and secretarial staff in the Department of Otolaryngology as well as insurance companies, patients and other Departments or clinical areas.

I. Preauthorization/Precertification 85%
A. Ensures all planned services are appropriately pre-authorized / pre-certified to secure the accurate billing process of patient procedure (e.g. diagnostic tests, inpatient and outpatient surgery, rehab, and DME's). This may involve discussion with the physician or nurse, reviewing the patient's medical record for necessary documentation and disseminating the appropriate information to the managed care/insurance company in order to secure approval of patient procedures.
B. Provide faculty and staff with updates regarding changes made to managed care/insurance procedures and/or protocols.
C. Assist in maintenance of 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 assure appropriate coverage for planned medical services.
E. Receive and respond to all patient calls regarding insurance questions, pre-certs, authorizations, etc.
F. Secure additional health information from the patient and/or physician regarding the episode of care being denied and initiates follow-up discussions with insurance organizations in order to obtain medical review.
G. Identifies, analyzes and takes necessary action in the review of insurance denials in order to determine the appropriate course of action required to accurately complete the medical review process.
H. Acts as liaison with patients, physicians, nurses, hospitals, government agencies, insurance companies, and managed care companies as required to identify and collect the information required to complete the authorization process and attempt to resolve problem claims.
I. Reviews and analyzes insurance processing procedures in order to identify potential problem areas in an effort to create a more streamlined, efficient procedure.
J. Counsels patients about their insurance coverage's eligibility and benefits, when required.
K. Obtain standard, established codes acquired from ICD-10 and CPT coding books after chart review and/or discussion with physician or nurse and disseminate to the certifying agency.
L. Maintain accurate records of preauthorization/precertification process through entering appropriate information in computerized data system.
M. Create computerized precertification forms to make the process more efficient.

II Administrative 15%
A. Attend training sessions, meetings and conferences and read publication to remain current on the policies and procedures of managed care/insurance companies.
B. Participate in SIU School of Medicine Committees, as requested.
C. Other duties/projects as assigned.

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.

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.

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"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.