Medical Insurance Specialist (U) (4583.1)

This person will serve as a lead worker of Medical Insurance staff, Denial team, assisting with orientating 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-certification denials of patient procedures for the Department of Surgery, as well as other Surgery Denials that are worked within the Department. This position will be responsible for assisting with maintaining a departmental managed care manual as well as updating and educating 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.

Surgery Claim Denials (75%)

• Ensures all planned services were appropriately pre-authorized to secure accurate billing process of patient procedures and services. This involves review of patient medical record for documentation and disseminating the appropriate information to the managed care/insurance plans in order to secure approved appeals, resubmitting denied claims and or corrective billing information.
• Investigating and tracking claim denials within the Department of Surgery. Reporting trends from the denial data to Supervisor and Administration.
• Assists in the accuracy of billing codes for ALL medical procedures related to the processing of pre-authorizations and pre-determinations. Ensuring planned services are appropriately preauthorized/pre-certified to secure the accurate billing process of patient procedures (e.g. diagnostic tests, inpatient and outpatient surgeries, rehab, DME).
• Reviews and interprets Medical Policy on Medicare and Medicaid plans to ensure that criteria has been met and that the plan will pay the claim.
• Provide faculty and staff with updated regarding changes made to managed care/insurance procedures and protocols. Educate providers, nursing staff on Medical policy for Medicare and Medicaid to ensure criteria met and documentation is sufficient.
• Maintain a central resource manual of managed care/insurance plans.
• Respond to inquiries from physicians, nurses, hospitals, government agencies, insurance companies, managed care companies and patients concerning requests for assistance to ensure reimbursement.
• Receive and respond to patient calls regarding insurance questions, billing issues, etc. Handling problems that may arise that are Insurance related in nature within the Department.
• 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.
• Review records and 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.
• 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 and or denial appeal.
• Obtain standard, established codes acquired from ICD-10 and CPT code books after chart review and or discussion with coding team, physician and or other insurance staff.

Administrative (25%)

• Attend training session, meeting and conferences and read publications to remain current on the policies and procedures of managed care/ insurance companies.
• Serve as a Lead Medical Insurance Specialist in the Department of Surgery Denial team, covering multiple divisions when needed. Being one of the contact persons for lower level insurance staff in the department, physicians, nurses, and staff as well as outside facilities to handle any problems that may arise with regards denials, coding issues, etc.
• Training of new Medical Insurance staff as needed and reporting employee progress to Supervisor/Administrator.
• Maintain and assist in creating/updating protocol manuals for the Denial team staff within the department. This position will also assist in monitoring workflow.
• Participate in SIU Physician & Surgeons committees as requested. Other duties and projects as assigned.

Qualifications

Any one or combination totaling two (2) years (24 months), from the categories below:

• 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).
• Work experience in a healthcare environment working independently with medical claims, denials, rejections, referrals, and prior authorizations.