Medical Insurance Associate (U) (4582)

This position serves as facilitator for SIU Center for Family Medicine - Springfield patients throughout the highly complex health care system. Responsibilities include serving as liaison with specialist offices and ancillary services (eg, lab, radiology, CT, MRI, major procedures) by coordinating the care patients receive among the different providers. In addition, this position serves as the primary contact for managed care and health maintenance organizations by obtaining the necessary approvals and documentation to proceed with providing services. This position involves direct contact with patients, averaging over 400 referrals per month per position.95% Internal & External Referral Coordination
1. Serve as patient advocate in securing referrals to specialist physicians and health care agencies.
2. Serve as liaison between managed care organizations and the physician's office, providing appropriate documentation for referrals, authori??ations for hospital, testing or other services.
3. Responsible for determining and disseminating the required information from the patient's medical records, i.e., chart notes, school physicals, laboratory results, x-rays, etc., to assure the medical necessity of the request to the consultant, and/or insurance/managed care company.
4. Develop or secure patient education materials that explain each type of test, what the expectations are of the patient, along with information regarding the medical facility.
5. Responsible for providing feedback to nursing staff for follow-up on patients referred for laboratory or radiology.
6. Maintain up to date files on all managed care organizations, employers under each plan, and their network of providers.
7. Maintain up to date directory of services provided to FQHC. patients by specialists and health care agencies.
8. Maintain list of managed care contacts for each organization and insurance company.
9. Advise faculty and resident physicians, nurses and other staff at the FQHC regarding the appropriateness and medical necessity guidelines of managed care referrals and authorization requests.
10. Maintain log of activity reports documenting volume for Supervisor.
11. Maintain log of health care agency contract addresses and telephone numbers by specialty area.

5% Other
12. Attend office managers meetings to keep abreast of managed care updates and insure compliance with managed care directives.
13. Participate in the development of appropriate forms for internal and external use as it relates to referrals.
14. Participate in staff meetings representing the Referral Unit.
15. Other duties as assigned.

1. Any one or combination totaling one (1) year (12 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)
   2. Work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and prior authorizations.