This position serves as the referral and preauthorization associate for SIU Center for Family Medicine - Decatur. This person will interact with physicians, nurses and support staff within FQHC - Decatur as well as insurance companies, patients and outside facilities. This position will be responsible for maintaining a departmental managed care manual as well as updating faculty and staff within the department of changes in the managed care process. This position performs daily application of the School's mission and vision in providing the highest level of quality care to our patients, families, and in working with our employees, physicians and communities we serve.

#IND1

Pre-Authorizations/Referrals 95%

1. Ensures planned services are appropriately pre-authorized/pre-certified to secure the accurate billing process of patient procedures (i.e. diagnostic test, inpatient and outpatient surgery, rehab and DME).

2. Secures referrals to specialty physicians, health care agencies and hospitals.

3. Works with physicians, mid-level providers, residents or nurses, reviewing the patient's medical record for necessary documentation and disseminating the appropriate information required for referrals or to complete the authorization process.

4. Provides faculty, mid-level providers, residents and staff with updates regarding changes made to managed care/insurance procedures and protocols.

5. Creates and maintains an updated central resource manual of managed care/insurance plans.

6. Responds to inquiries from physicians, mid level providers, residents, nurses, hospitals, government agencies, insurance companies, managed care companies and patients concerning requests for assistance to assure appropriate coverage for planned medical services.

7. Receives and responds to patient calls regarding insurance questions, pre-certs, authorizations, etc.

8. 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.

9. Secures additional health information from the patient and/or physician regarding the episode of care being denied and initiates follow-up discussions with insurance organizations in order to obtain medical review.

10. Obtains standard, established codes acquired from ICD-10 and CPT books after chart review and/or discussion with physician or nurse and disseminates to the certifying agency.

11. Maintain accurate records of the pre-authorizations/pre-certification process through entering appropriate information in computerized data system.

12. Utilizes the Electronic Health Record and IDX for entering and tracking pre-certification forms to make the process more efficient.

Administrative 5%

1. Attends and participates in training sessions, meetings and conferences and reads publications to remain current on the policies and procedures of managed care/insurance companies.

2. Other duties and projects as assigned.

1. Any one or combination totaling two (2) years (24 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)
      • 90 semester hours equals two (2) years (24 months)
   2. Work experience in a healthcare environment working independently with medical claims, denials, rejections, referrals, and prior authorizations.

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.

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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.