"Medical Insurance Specialist (U) (4583)"

The function of this position examines and analyzes explanation of benefits to determine if correct payment has been made or to determine how to receive maximum benefits from third party payer. The incumbent routinely reviews outstanding invoices to determine action steps needed to resolve the balance. The incumbent assist with training of new staff and assist lower level Medical Insurance staff with questions.

THIS POSITION IS ON SITE ONLY!

70% Invoice Follow-up

• Works independently and closely with Team Manager
• Completes all complex task as assigned by the Team Manager
• Reviews explanation of benefits (eob) for denials
• Access patient account in the Centricity Business billing system.
• Determine action needed and proceed appropriately.
• Responds to a variety of questions of lower level Medical Insurance staff concerning proper action needed to complete insurance claim forms.
• Assist in training and evaluations of new Medical Insurance staff.
• High level of knowledge and experience in reviewing complex accounts in addition to new insurance plans. Bill secondary insurance when appropriate.
• Transfer denied charge to patient or another responsible party as needed.
• Order medical notes when needed.
• Submit denial information to the medical coding staff in the clinical departments for review and coding decisions. Track request for coding review. Resubmit claims based on the coding reviewer response or take write-offs as directed.
• Review charges that are paid to determine if further review is necessary.
• Process appropriate adjustment/write off for denied charges that do not need medical coding review (non­covered service, untimely filings, etc.)
• Update patient insurance information, such as correct insurance billing addresses and insurance plan effective/termination dates.
• Order insurance claim forms and resubmit charges.
• Retrieves eobs from CD rom, microfilm or other hard copy records and files as needed.
• Make appropriate entry of actions taken in the billing system modules.
• Open, print and close batch proof; balance after daily use.
• Contact insurance companies or patients for information needed to submit claims, such as billing addresses or plan effective/termination dates.

15% Insurance Follow-up

• Contact insurance company representatives to discuss denials and zero pays.
• Able to make complex decisions when resolving accounts, take appropriate action steps including resubmission, adjustments, request for review, etc.
• Forward to immediate supervisor or manager if necessary.
• Request telephone reviews of claims if appropriate.
• Make appropriate entry of actions taken in the billing system modules.

10% Correspondence

Opens and reviews incoming mail related to the payer team. Responds to complex correspondence as needed or as instructed by the Insurance Assistant Manager.

5%- Other duties as assigned. Maintain personal Procedure Manual with current procedures for reference.

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)

• Ability to effectively communicate with faculty, staff and patients in either person or by phone.
• Ability to keyboard on computer terminals.
• Ability to meet established guidelines and follow policies and procedures established by the SIU Healthcare, HCF A and other federal/state agencies.
• Tolerance for tedious and repetitious work.
• Ability to work accurately with details.
• Ability and desire to greet patients/visitors in a pleasant and professional manner.
• Ability to work within specific deadlines.
• Demonstrates, by action commitment to the mission and the behavioral standards of SIU School of Medicine. Provides excellent service to both internal and external customers through collaboration and partnership; compassion and respect; integrity and accountability; diversity and inclusion; as well as continuous learning and improvement.
• Sensitive to the needs of underrepresented minority populations.
• Ability to multitask and complete job duties amid various distractions.

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.