Medical Insurance Specialist (U) (4583)

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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 the third-party payer. The incumbent is responsible for monitoring contractual allowances, analyzing, and pursuing appeal opportunities with payers and networks, and reporting appeals performance.

Invoice Analyst 70%
Establishes a process for identifying under-allowed claims using Experian Health Contract Manager and other available tools.
Reviews and analyzes Payer EOB/Remit information to ensure appropriate payment posting.
Verifies Payer member information, patient ID card and/or eligibility to ensure appropriate registration.
Compiles and submits appeals to Payers using various methods.
Identifies and compiles batch appeals by payer or network, by CPT/HCPCS/Revenue code/DRG code combination, by error type or by provider.
Uses Contract Manager to track appeals and recoveries.
Uses feedback and experience to continuously improve communication skills for use in preparing written and telephone appeals.
Establishes and cultivates helpful and effective contacts in payer or network offices.
Establishes follow-up protocol with payers and networks.
Uses Contract Manager's functionality to prepare monthly performance statistics regarding appeals and recoveries.
Monitors and tracks contractual, billing, registration, and posting errors, and provides continuous feedback to Management.
Participates in meetings to discuss ongoing trends and issues regarding the administration of managed care contracts.
Insurance Follow Up 15%
Contact Insurance company representatives to discuss under/over payment trends.
Able to make complex decisions when resolving accounts, take appropriate action steps to ensure proper insurance payments.
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.
Correspondence 10%
Responds to complex correspondence as needed or as instructed by the Medical Insurance Assistant Manager.
Other Duties as Assigned 5%
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.

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 complex medical terminology, hospital or physician billing and coding, referrals, and prior authorizations.
4. Knowledge of arithmetic with the ability to add, subtract, multiply and divide whole numbers, decimals and percentages.
5. Skill in evaluating information to determine compliance with standards. Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, standards and ensuring that lower-level employees are following standards.
6. Skill in using computers and computer systems (including hardware and software) to program, write, set up functions, enter data, or process information.
7. Ability to pay close attention to details, follow established procedures to complete work tasks and train others in those procedures.
8. Ability to maintain patient confidentiality following HIPAA guidelines and established policies and procedures.
9. Ability to train others and work collaboratively, building strategic relations with colleagues, coworkers, constituents.
10. Ability to plan, assign, and supervise the work of others.

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.

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.