Medical Insurance Specialist; U

This person will serve as a lead worker of Medical Insurance staff, orientate new staff, and serve as a resource to all staff, residents, physicians and nurses in the Department of Surgery. This person will be responsible for the pre-authorizations/pre-certifications of patient procedures for the Department of Surgery. This position will be responsible for assisting with maintaining a departmental managed care manual as well as updating faculty and staff within the department of changes in the managed care process.

This person will interact with physicians, nurses and supportive staff within the Department of Surgery, as well as insurance companies, patients and outside facilities.

* This position is ON SITE only*

• A. Verifies accuracy of billing codes for ALL medical procedures related to the processing of pre-authorizations and pre-determinations. Ensures planned services are appropriately preauthorized/precertified to secure the accurate billing process of patient procedures (e.g. diagnostic tests, inpatient and outpatient surgeries, rehab, DME). This involves discussion with the physician or nurse, reviewing patient’s medical record for necessary documentation and disseminating the appropriate information to the managed care/insurance company in order to secure approval of the patient procedure(s).
• B. Provide faculty and staff with updated regarding changes made to managed care/insurance procedures and protocols.
• C. Maintain a central resource manual of managed care/insurance plans.
• D. Respond to inquiries from physicians, nurses, hospitals, government agencies, insurance companies, managed care companies and patients concerning requests for assistance to ensure appropriate coverage for planned medical services.
• E. Receive and respond to patient calls regarding insurance questions, precerts, authorizations, billing issues, etc.
• F. Identifies, analysis and takes necessary action in the review of insurance denials in order to determine appropriate course of action required to accurately complete the medical review process for appeal and resolution.
• 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 medical review.
• H. Correspond with physicians, nurses, hospitals, government agencies, insurance companies, managed care companies and patients as required to identify and collect the information required to complete authorization process.
• I. Obtain standard, established codes acquired from ICD-10 and CPT code books after chart review and or discussion with physician or nurse and disseminate to the certifying agency.
• J. Maintain accurate record of preauthorization./predetermination through entering appropriate information in the computerized data systems.
• K. Create computer precertification forms to make process more efficient.

• A. Attend training session, meeting and conferences and read publications to remain current on the policies and procedures of managed care/ insurance companies.
• B. Serve as a Lead Medical Insurance Specialist in the Department of Surgery, being one of the main contact persons for lower level specialists in the department, physicians, nurses, and staff as well as outside facilities to handle any problems that may arise with regards to lower level insurance staff, complex procedures, etc.
• C. Assist in the training and evaluating of new and lower level Medical Insurance staff I the Department of Surgery
• D. Maintain and assist in updating procedure manuals for all Medical Insurance staff within the department. This position will assist in monitoring workflow and making…