Medical Insurance Representative (U) (4581)

Under direct supervision, the Medical Insurance Representative functions in a training capacity and is assigned routine, non-complex medical/health claims, referrals, and prior authorizations.

1. for supervisor's review interprets codes or procedure(s) performed according to coding standards, which may require the interpretation and selection of the codes provided by or to the insurance carrier;
2. under direct supervision, reviews and analyzes itemized claims/bills or non-complex claim forms for consistency (i.e., ensures that services rendered by the physician or hospital are compatible with the diagnosis or treatment) and investigates discrepancies to determine the appropriate course of action required to accurately complete the claim processing, billing procedure, or adjudication process;
3. responds to a variety of questions from physicians, patients, hospitals, insurance companies, government agencies, and related interested parties concerning the status of medical bills, referrals, and prior authorizations;
4. corresponds with and responds to a variety of inquiries from health care providers, patients or plan members, insurance companies, government agencies, and related interested parties concerning the status of persons utilizing the services of a facility as required to identify, collect, and analyze the information to process simpler claim forms properly;
5. understands and applies basic medical terminology, coding, and billing and maintains an up-to-date understanding of billing and industry regulations;
6. reviews and analyzes routine payment, capitation, adjustment, or denial records and posts or adjusts records as required under the direct supervision of a supervisor.
7. serves as a liaison between insurance and providers to ensure coverage and benefits before treatment, acts as a patient advocate in securing and scheduling referrals, pre-authorizations, or pre-certifications;
8. under direct guidance from a supervisor, tracks, reports, and resolves simple third-party denials;
9. processes mail and correspondence identified to be a part of the billing and receivable function;
10. completes and submits payer-specific claim forms (paper, electronic, and other) and submits claim forms to payers through electronic billing systems, as required by the payer;
11. performs other related duties as assigned.

1. High school diploma or equivalent.
2. Any one or combination totaling six (6) 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 six (6) months
   2. Work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and/ or prior authorization.

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.

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"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.