"Medical Insurance Representative"

This person will serve as a Medical Insurance Associate on the denials team within the Department of Surgery. This person will be responsible for all aspects of denials, appeals and missing preauthorizations/pre-certifications of patient procedures for the Department of Surgery. This person will interact with physicians, nurses and supportive staff within the Department of Surgery, as well as insurance companies, and outside facilities.

I. Claim Denials and Appeals 85%

Ensures all planned services were appropriately preauthorized to secure the accurate billing process of patient procedures (e.g., inpatient and outpatient surgery, rehab, Drug and DME). This involves reviewing the patient's medical record for documentation and disseminating the appropriate information to the managed care/insurance company in order to secure approved appeals of the patient procedures. Resubmitting denied claims with appeals and/or corrective billing information.

Provide faculty and staff with updates regarding changes made to managed care/insurance procedures and protocols.

Receive and respond to communication regarding insurance questions, missing or incorrect prior authorizations, denials, appeals, etc.

Working ETM Tasks: 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. Working closely with the Coding and PBS team to resolve denied claims.

Secure additional health information from the patient and/or physician regarding the episode of care being denied and initiates follow-up discussions and appeals with insurance organization in order to obtain medical review.

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.

Obtain standard, established codes acquired from ICD-9 and CPT books after chart review and/or discussion with physician or nurse and disseminate to the certifying agency.

II. Administrative 15%

Attend training sessions, meetings and read publications to remain current on the policies and procedures of managed care/insurance.

Participate in SIU Healthcare committees as requested.

Collecting denial data /report findings to Medical Insurance Assistant Manager/Administrator.

Participate in SIU Physician & Surgeon meetings as requested.

Other duties and projects as assigned.

Qualifications

1. High school diploma or equivalent.

2. Any one or combination totaling six (6) months from the categories below:

a. 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 six (6) months.

b. Work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and/or prior authorization.