Medical Insurance Associate (U) (4582)

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This person will be responsible for the preauthorization/precertification of patient procedures for the Department of Surgery. 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 as well as insurance companies, patients and other departments or clinical areas.

Preauthorization /Precertification/Predetermination: 85%
A. Ensures all planned services are appropriately preauthorized/precertified to secure the accurate billing process of patient procedure (e.g. diagnostic tests, inpatient and outpatient surgery, rehab, and DME's). This involves 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 the 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, percerts, authorizations
F. 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.
G. 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
H. Correspond with physicians, nurses, hospitals, governments agencies, insurance companies, managed care companies and patients as required to identify and collect the information required to complete the authorization process
I. Obtain standard, established codes acquired from ICD-9 and CPT coding books after chart review and/or discussion with physician or nurse and disseminate to the certifying agency.
J. Maintain accurate records of preauthorization/precertification processes through entering appropriate information into computerized data system.
K. Create computerized forms to make process more efficient
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 Physicians & Surgeons committees as requested.
C. Other duties/projects as assigned.

Credentials to be Verified by Placement Officer:

1. Any one or combination totaling one (1) year (12 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)
   2. Work experience in a healthcare environment working 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 medical terminology and hospital or physician billing, coding, referrals, and prior authorizations.
4. Knowledge of basic arithmetic with the ability to add, subtract, multiply and divide whole numbers, decimals and percentages.
5. Skill in using computers and computer systems (including hardware and software) to program, write, set up functions, enter data, or process information.
6. Ability to pay close attention to details and follow established procedures in completing work tasks.
7. Ability to maintain patient confidentiality following HIPAA guidelines and established policies and procedures.
8. Ability to convey moderately complex billing, claims, referral, and prior authorization information to patients and staff.
9. Ability to train others to work collaboratively, building strategic relations with colleagues, coworkers, constituents.

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.

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