SIU Medicine
Location
Springfield, IL | United States
Job description
This position is responsible for oversight and coordination of the medical insurance/referral and clinical charge coding/posting functions of the Department of Obstetrics and Gynecology. This position is responsible for direct supervision of the referral, coding and posting staff. The incumbent must exercise sound judgment and work independently to ensure that billing issues from patients, physician faculty and residents, hospitals, federal and state insurance programs, managed care companies, community agencies and other parties are resolved. This position serves as facilitator for patients throughout the highly complex health care system.
Administration 45%
1. Directly supervises the OB/GYN Department Referral Staff assisting with setting daily priorities to ensure all referrals are processed in a timely manner.
2. Select, train, supervise and evaluate all clinic referral staff including disciplinary action as required.
3. Responsible for approving employee time off requests and ensuring employee time records are accurate.
4. Participates in the development and implementation of the orientation plan for new staff; assisting with training and orientation activities for all referral office staff. Provide guidance, as needed, for new team members.
5. Participates in the development of appropriate forms for internal and external use as related to referral activities.
6. Coordinates and facilitates referral staff meetings.
7. Obtains appropriate signed forms for compliance with SIU Medicine, HIPAA and insurance companies' regulations.
8. Remains abreast of changes in the medical necessity guidelines and provides updates to staff.
9. Develops and educates providers on appropriate documentation needed for managed care plans and preauthorizations for medical services.
10. Provides guidance in all atypical situations for the referral unit.
11. Implements new procedures, policies, workflow as needed based on insurance
changes/departmental needs, software changes and upgrades.
12. Participates in developing written protocols, job aids, policies, workflow and standards for GEB and TouchWorks.
13. Works with SIUSOM GE and EHR system support departments to create, implement, and improve the billing and medical record systems, forms, and workflow.
Insurance Processing 35%
1. Determines when patients with insurance plans need waiver of benefit notices signed and explains peocess to patients.
2. Maintains up to date files on all managed care organizations, employers under each plan, and their network of providers and keep staff up to date on any changes in coverage.
3. Maintains list of managed care contacts and addresses for each organization and insurance company and ensure all staff have the most up to date information available.
4. Serves as liaison with managed care companies concerning status of referrals and authorizations to resolve referral issues and adjudicate claims disputes.
5. Corresponds with patients to answer all inquiries and to assist them in adjudicating claims where disputes over referrals and authorizations are involved.
6. Advises faculty and resident physicians, nurses and other staff regarding the appropriateness and medical necessity guidelines of managed care referrals and authorization requests.
7. Maintains log of activity reports documenting volume for Supervisor.
8. Maintains log of health care agency contract addresses and telephone numbers by specialty area.
9. Investigates and follows up verbally, or in writing, with patients or insurance companies regarding account/billing discrepancies. Coordinates adjustments with billing and/or coding department.
10. Assists administration with training and education of lower level support staff.
Support for Direct Patient Care 15%
1. Serves as patient advocate in securing referrals to specialist physicians and health care agencies.
2. Serves as liaison between managed care organizations and the physician's office, providing appropriate documentation for referrals, authorizations for hospital, testing or other services.
3. Determines and disseminates 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. Develops or secures patient education materials that explain each type of test, what the expectations are of the patient, along with information regarding the medical facility.
5. Provides feedback to nursing staff for follow-up on patients referred for laboratory or radiology.
6. Responds to a variety of questions from physicians, hospitals, and insurance companies concerning the status of insurance claims.
7. Oversees that patient family medical leave paperwork is completed correctly and in a timely manner.
8. Handles patient requests/telephone calls regarding the referral process.
Sevices/Miscellaneous 5%
1. Serve as a resource for other SIU Departmental Referral Staff by assisting in training them in the use of the electronic health record and the referral process.
2. Attend SIU Medicine Managed Care Networking meetings to keep abreast of managed care updates, and insure compliance with managed care directives.
3. Other duties as assigned.
If you require assistance, please contact the Office of Human Resources at [email protected] 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.
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