Medical Insurance Associate (4582)

This position serves as facilitator for SIU Center for Family Medicine - Springfield patients throughout the highly complex health care system.

Responsibilities

• Serve as liaison with specialist offices and ancillary services (e.g., lab, radiology, CT, MRI, major procedures) by coordinating the care patients receive among the different providers.
• Serve as the primary contact for managed care and health maintenance organizations by obtaining the necessary approvals and documentation to proceed with providing services.
• Act as patient advocate in securing referrals to specialist physicians and health care agencies.
• Liaise between managed care organizations and the physician’s office, providing appropriate documentation for referrals, authorizations for hospital, testing, or other services.
• Determine and disseminate required information from patient medical records (e.g., chart notes, school physicals, laboratory results, x-rays) to assure medical necessity of requests to consultants and/or insurance/managed care companies.
• Develop or secure patient education materials explaining each type of test, patient expectations, and information regarding the medical facility.
• Provide feedback to nursing staff for follow-up on patients referred for laboratory or radiology.
• Maintain up-to-date files on all managed care organizations, employers under each plan, and their network of providers.
• Maintain an up-to-date directory of services provided to FQHC patients by specialists and health care agencies.
• Maintain a list of managed care contacts for each organization and insurance company.
• Advise faculty, resident physicians, nurses, and other staff regarding the appropriateness and medical necessity guidelines of managed care referrals and authorization requests.
• Maintain logs of activity reports documenting volume for supervisor and health care agency contract addresses/telephone numbers by specialty area.
• Attend office managers meetings to stay updated on managed care changes and ensure compliance with directives.
• Participate in the development of appropriate forms for internal and external use related to referrals.
• Participate in staff meetings representing the Referral Unit.
• Other duties as assigned.

This position involves direct contact with patients, averaging over 400 referrals per month.

Requirements

Credentials to be verified by placement officer: Any one or combination totaling one (1) year (12 months) from the categories below:

• College coursework in a health-related field, business administration/management, human resource management, or closely related fields:
  • 30 semester hours equals one (1) year (12 months)
  • Associate’s Degree (60 semester hours) equals eighteen months (18 months)
• Work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and prior authorizations.

Skills

• Knowledge of principles and processes for providing customer and personal services, including needs assessment, quality standards, and customer satisfaction evaluation.
• Knowledge of English language structure, spelling, grammar, and composition.
• Knowledge of medical terminology and hospital or physician billing, coding, referrals, and prior authorizations.
• Knowledge of basic arithmetic, including addition, subtraction, multiplication, division of whole numbers, decimals, and percentages.
• Skill in using computers and computer systems to program, write, set up functions, enter data, or process information.
• Ability to pay close attention to details and follow established procedures.
• Ability to maintain patient confidentiality following HIPAA guidelines and established policies.
• Ability to convey moderately complex billing, claims, referral, and prior authorization information to patients and staff.
• Ability to train others to work collaboratively and build strategic relations with colleagues, coworkers, and constituents.

Conditions of Employment

• Pursuant to the State Universities Civil Service System, an out-of-state resident hired into this position must establish Illinois residency within 180 calendar days of their start date.
• Pre-employment background screenings required.