Medical Insurance Representative (U) (4581)

The function of this position examines and analyzes insurance invoices that have no activity or have been transferred to the insurance level for follow-up. Review explanation of benefits to determine if correct payment has been made or to determine how to receive maximum benefits from the third party payor. The incumbent routinely reviews outstanding invoices to determine action steps needed to resolve the balance. This is an entry level position which functions in a training capacity under direct supervision processing routine, non-complex medical/health claims.

Invoice Follow Up - No Activity 85%
Contact Insurance Company for Claim Status
Reviews Explanation Of Benefits (EOB) for denials
Access patient account in the Athena billing system.
Determine action needed and proceed appropriately.
Transfer denied charge to patient or another responsible party as needed. Retrieves EOB's for submission to insurance carriers.
Make appropriate entry of actions taken in the billing system modules.

Insurance Follow Up 10%
Contact Insurance company representatives to discuss denials and zero pays.
If easily resolved, take appropriate action steps including resubmission, adjustments, request for review, etc.
Forward to immediate supervisor or manager if necessary.
Bill secondary insurance when appropriate.
Review charges that are paid to determine if further review is necessary.
Order medical notes when needed
Request telephone reviews of claims if appropriate.
Request appropriate adjustment/write off for denied charges that do not need medical coding review (non-covered service, untimely filings, etc.)
Make appropriate entry of actions taken in the billing system modules.

Correspondence 2%
Responds to routine correspondence as needed.

Other Duties 3%
Other duties as assigned

Credentials to be Verified by Placement Officer

1. High school diploma or equivalent.
2. Any one or combination totaling six (6) 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 six (6) months
   2. Work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and/ or prior authorization.

Knowledge, Skills & Abilities (KSA's)

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 basic medical terminology of basic 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.
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 routine, non-complex billing, claims, referrals, and prior authorization information to patients and staff.
9. Ability to work collaboratively, building strategic relations with colleagues, coworkers, constituents.

Condition of Employment

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