Medical Insurance Specialist - Carbondale (4583)

The person in this position performs functions related to referrals and prior authorizations. Responsibilities include serving as liaison with specialist offices, insurance companies, and ancillary services (eg, lab, radiology, CT, MRI, major procedures) by assisting in the care patients receive among the different providers. This position fosters a team approach by working collaboratively with the patient, family, physician, and other members of the health care team to ensure services are provided in an efficient and effective manner. This person assists in training staff, and developing and maintaining policies and procedures.

The following information is intended to be representative of the work performed by incumbent in this position and is not all-inclusive. The omission of a specific duty or responsibility will not preclude it from the position if the work is similar, related, or a logical extension of position responsibilities.

Demonstrates, by actions, 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.

90% Referrals & Prior-Authorizations

1. Maintains patient medical records in accordance to policy.
2. Assists in completing patient referrals and pre-authorizations:

1. Assists patients with securing referrals to specialist physicians, health care agencies, and hospitals.
2. Works with managed care organizations and the physician's office, providing appropriate documentation for referrals, authorizations for hospital, testing or other services.
3. Responsible for determining and disseminating the required information from the patient's medical records, i.e., chart notes, school physicals, laboratory results, x-rays, etc., to assure the medical necessity of the request to the consultant, and/or insurance/managed care company
4. Helps to maintain up-to-date directory of services provided to SIU Center for Family Medicine - Carbondale patients by specialists and health care agencies.
5. Contacts managed care companies concerning status of referrals and pre-authorizations.

1. Keeps faculty physicians, resident physicians, nurse practitioners, physician assistants, nurses and other staff at the clinic informed about the requirements and medical necessity guidelines of managed care referrals and authorization requests.
2. Provides feedback regarding the development of appropriate forms for internal and external use as it relates to referrals and pre-authorizations.
3. Helps to maintain log of health care agency addresses and telephone numbers by specialty area.
4. Maintains the ability to appropriately handle referrals, schedule appointments, answer general patient questions; knowledgeable about procedures and services.
5. Maintains up-to-date on Medicare, Medicaid and Managed Care Guidelines.
6. Helps to monitor referral reports, and assists with timely follow-up in accordance with policy and procedure.
7. Enters referral and preauthorization information into the electronic medical records and computer system according to policy and procedure.

1. Maintains operating knowledge of the following systems IDX, TouchWorks, MEDI and Cerner.

10% Training and Staff Coordination

1. Trains new staff on referral and prior authorization processes.
2. Coordinates with off-site staff, setting and adjusting priorities as needed.
3. Maintains referral resources, updating and distributing to all on and off-site staff.
4. Helps with call center coverage on an emergent basis, answering incoming calls and tasking.

1. Sensitive to the needs of underrepresented minority populations.
2. Medical office experience with a basic knowledge of insurance and/or referral processing.
3. Possess high job accuracy, efficiency, and dependability.
4. Must be computer literate and possess the ability to work within Microsoft Word, Excel, multiple electronic health records, and appointment scheduling system.
5. Possess knowledge of third-party payer reimbursement plans, including Medicare, Medicaid and managed care organizations.
6. Demonstrates outstanding customer service skills, communicates well (both verbal and written) and utilizes excellent listening skills and telephone etiquette.
7. Pleasant disposition and high comfort level in dealing with patients, faculty and residents.
8. Ability to handle stressful situations.
9. Maintain a high level of customer satisfaction and retention.
10. Strong attention to detail and accuracy required.
11. Maintain customer/patient confidentiality.
12. Must be self-motivated and able to work independently and with a group setting.
13. Ability to document and report findings and observations.
14. Possess great organizational skills with the ability to multi task, set priorities, and meet deadlines, with the guidance of a supervisor.

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.

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.

The mission of Southern Illinois University School of Medicine is to optimize the health of the people of central and southern Illinois through education, patient care, research and service to the community.

The SIU School of Medicine Annual Security Report is available online at https://www.siumed.edu/police-security. This report contains policy statements and crime statistics for Southern Illinois University School of Medicine in Springfield, IL. This report is published in compliance with Federal Law titled the

"Jeanne Clery Disclosure of Campus Security Policy and Crime Statistics Act."

Southern Illinois University School of Medicine is an Affirmative Action/Equal Opportunity employer who provides equal employment and educational opportunities for all qualified persons without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, protected veteran status or marital status in accordance with local, state and federal law.

Pre-employment background screenings required.