Springfield IL - Medical Insurance Specialist

About the role

The position is intended to be eligible for benefits, including Health, Dental, Vision, Life Insurance, a Retirement Plan, Paid Time Off, and Tuition waivers for employees and dependents.

Responsibilities

• Analyze, process and adjust paper & electronic claims for accuracy.
• Reviews case specific information to enter the prior approval for claim adjudication.
• Resolve complex collections, provider and customer complaints independent of manager oversight.
• Train providers to use the Provider Portal application and provides instructions on procedures and policies for claims adjudication.
• Determines the policy provision for complex nursing and medical claims. Communicates findings with DSCC staff and providers. Determines a resolution to process the claim.
• Reviews and analyzes provider claims and insurance explanation of benefits for quality assurance.
• Serves as the primary point of contact for providers, DSCC staff and families in various situations.
• Determines appropriate adjustments needed when explanation of benefit’s, refund checks or claims are resubmitted by providers or families.
• Initiates, receives and documents telephone calls to facilitate claims payment process.
• Serves as the primary point of contact for providers, DSCC staff and families in various situations.
• Communicates findings with DSCC staff and providers.
• Attends Division and university related meetings and serves as a departmental liaison in the absence of the manager.
• Trains new and lower level staff on unit policies and procedures, including processing of claims.
• Reports and training issues to claims manager.
• Identifies needs/problems with computer software programs and agency claims processing practices, makes recommendations for change or enhancement to manager.
• Conducts file audits to obtain reimbursement of DSCC expenditures due to benefit coverage changes, claims processed incorrectly by insurance carriers and discrepancies of insurance benefit coverage.
• Prepares reports or written correspondence for the manager as requested.
• Aids in revising the Home Care and Core Department Manual.
• May supervise lower level staff as assigned in the absence of the department manager.
• Conducts quarterly quality assurance audits on finalized claims based on departmental guidelines.
• Other duties 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.