Medical Insurance Specialist

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.

70% Invoice Analyst:
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.
Maintains the strict confidentiality required for medical records and other data.
Participates in professional development efforts to ensure currency in managed care reimbursement trends.
Access patient account in the Centricity Business billing system.
Make appropriate entry of actions taken in the billing system modules.
Open, print and close batch proof; balance after daily use.
Able to make complex decisions when resolving account under/over payments, and work independently.

15% Insurance Follow-up:
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.

10% Correspondence:
Responds to complex correspondence as needed or as instructed by the Medical Insurance Assistant Manager.

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

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.