Springfield, IL - Medical Insurance Specialist (Core)

Medical Claims Analyst

Position Summary : Review, analyze and enter medical claims, interpret third party payment information, coordinate benefit coverage information in order to determine DSCC financial liability.

Employees at this level are senior representatives under limited supervision who provide technical assistance and guidance to DSCC staff, providers and families on complex issues independent of manager oversight to facilitate medical claims processing.

Duties & Responsibilities :

• Analyze, process and adjust paper & electronic claims for accuracy. Reviews case specific information to enter the prior approval for claim adjudication.
• Resolve complex collections, provider and customer complaints independent of manager oversight.
• Train providers to use the Provider Portal application and provides instructions on procedures and policies for claims adjudication.
• Determines the policy provision for complex nursing and medical claims. Communicates findings with DSCC staff and providers. Determines a resolution to process the claim.
• Reviews and analyzes provider claims and insurance explanation of benefits for quality assurance. Initiates, receives and documents telephone calls to facilitate claims payment process. Serves as the primary point of contact for providers, DSCC staff and families in various situations.
• Determines appropriate adjustments needed when explanation of benefit's, refund checks or claims are resubmitted by providers or families.
• Attends Division and university related meetings and serves as a departmental liaison in the absence of the manager.
• Trains new and lower level staff on unit policies and procedures, including processing of claims. Reports and training issues to claims manager.
• Identifies needs / problems with computer software programs and agency claims processing practices, makes recommendations for change or enhancement to manager.
• Conducts file audits to obtain reimbursement of DSCC expenditures due to benefit coverage changes, claims processed incorrectly by insurance carriers and discrepancies of insurance benefit coverage.
• Prepares reports or written correspondence for the manager as requested.
• Assists manager on revisions to the Home Care and Core Department Manual.
• May supervise lower level staff as assigned in the absence of the department manager.
• Conducts quarterly quality assurance audits on finalized claims based on departmental guidelines.
• Other duties as assigned.

Minimum Qualifications :