Medical Insurance Specialist (U)(4583)

SIU Medicine; Springfield (IL); Presencial; USD 50.000 - 75.000; Jornada completa

Descripción de la vacante

SIU Medicine seeks a Lead Medical Insurance Specialist to coordinate preauthorization and precertification activities in the Department of Surgery. You will verify codes, update procedures, and act as a main contact for staff and external partners.

You will train junior staff, maintain manuals, and respond to inquiries from physicians, insurers, and patients. This on-site role requires strong knowledge of managed care processes and HIPAA compliance.

Formación

• Experience in preauthorization and precertification workflows preferred.
• Familiar with ICD-10 and CPT coding and billing processes.
• Ability to train and supervise junior staff in insurance procedures.

Responsabilidades

• Verify codes for preauthorizations and precertifications for procedures.
• Disseminate updated managed care procedures to staff and faculty.
• Maintain a central manual of managed care plans.
• Respond to inquiries from physicians, nurses, hospitals, insurers, and patients.
• Handle patient calls regarding insurance questions and precerts.
• Review insurance denials and coordinate appeals as needed.
• Obtain additional health information and contact insurers for reviews.
• Correspond with care teams to gather required authorization data.
• Disseminate ICD-10 and CPT codes after chart review.
• Document preauthorization data in computerized systems.
• Create precertification forms to improve efficiency.
• Lead and train lower level Medical Insurance staff.
• Assist in updating procedure manuals and monitor workflow.
• Participate in SIU Physician & Surgeons committees as requested.

Conocimientos

Customer service

English language

Medical terminology

Arithmetic

Compliance knowledge

Computer literacy

Attention to detail

HIPAA confidentiality

Training others

Supervisory skills

Educación

Healthcare coursework

Work experience in medical claims

Herramientas

Medical billing software

Descripción del empleo

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.

*This position is ON SITE only*

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 25%

• 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. Other duties and 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.

Knowledge, Skills & Abilities (KSAs)

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.