Description

The incumbent in the position processes preauthorizations / precertifications forms for the

Department of Surgery. This person will assist in maintaining a departmental managed care

manual as well as updating faculty and staff in the department regarding changes in the

managed care process. This person will interact with physicians, nurses, and secretarial staff in

the Department of Surgery as well as insurance companies, patients, and other departments or

clinic areas.

Examples of Duties

Preauthorization / Precertification 85%

A. Verifies accuracy of billing codes of routine, non-complex medical health claims related

to processing of pre-authorizations / precertifications of patient procedures (,,

diagnostic tests ,inpatient and outpatient surgery, rehab and DME). This involves

discussion with physician or nurse, reviewing the patients medical record for necessary

documentation and disseminating the appropriate information to the managed

B. Provide faculty and staff with updates regarding changes made to managed

care / insurance procedures and / or protocols.

C. Assist in maintenance of a central resource manual of managed care / insurance

company plans.

D. Respond to routine, non-complex inquiries from physicians, nurses, hospitals,

government agencies, insurance companies, managed care companies and patients

concerning requests for assistance to assure appropriate coverage for planned medical

services.

E. Receive and respond to patient calls regarding insurance questions, precerts,

authorizations, etc.

F. Identifies, analyzes and takes necessary action in the review of insurance denials in

order to determine the appropriate course of action required to accurately complete

the medical review process.

G. Secure additional health information from the patient and / or physician regarding the

episode of care being denied and initiate follow-up discussions with insurance

organizations in order to obtain a medical review.

H. Correspond with physician, nurses, hospitals, government agencies, insurance

companies, managed care companies, and patient as required to identify and collect

the information required to complete the authorization process.

I. Obtain standard, established codes acquired from ICD-9 and CPT coding books after

chart review and / or discussion with physician or nurse and disseminate to the certifying

insurance agency.

J. Maintain accurate records of preauthorization / precertification process through

entering appropriate information into computerized system.

K. Create computerized precertification forms to make the process more efficient.

II. Administrative 15%

A. Attend training sessions, meetings, and conferences and read publications to remain

current on the policies and procedures of managed care / insurance companies.

B. Participate in SIU Physicians & Surgeons committees as requested.

C. Other duties / projects as assigned.

Qualifications

Any one, or any combination, that totals 6 months from the following :

a. Experience within a health insurance / medical billing environment; or

b. Medical billing certification from an accredited program (, Certified Professional Coder (CPC); Registered Health Information Technician (RHIT);

Certified Coding Specialist (CCS); Registered Health Information Administrator (RHIA); National Healthcareer Association (NHA)); or

c. College course work in Insurance / Benefits Administration, Human Resource Management, Health Information Management, Finance, Accounting or closely related fields such as Business Administration and / or business Management (30 semester hours 6 months)

Supplemental Information

If you require assistance, please contact the Office of Human Resources at 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 . 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.

Last updated : 2024-04-23