Medical Insurance Series

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This series is designed for employees who examine and analyze standardized health claims/bills and take the appropriate action to correct, collect or adjudicate these claims/bills.   Including the preparation of claim/billing forms for presentation to third-party payers or the preparation of vouchers for the direct payment of claims/bills.  In addition, employees may investigate and identify potential payment sources for patients or possible payment from other insurance carriers or responsible, liable sources.

Employees apply appropriate administrative, technical, and physical safeguards to protect the privacy and security of protected health information (PHI) as mandated by the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH).

Employees may act as a liaison between insurance companies, provider’s office, and/or ancillary services to obtain prior authorization for appointments and procedures to ensure payment of claims. Medical Insurance personnel may supervise lower-level employees and related support staff assigned to the billing, receivables, or claims processing.

Medical Insurance personnel typically:

1. reviews itemized charges, claims/bills, or personal data forms for accuracy and/or completeness and makes the necessary corrections;
2. completes insurance claim forms, transmits, collects, or adjudicates claims based on the data that is provided on itemized bills, claim worksheets, or hospital admissions records, which requires the identification and interpretation of the information to be coded and recorded on the claim forms;
3. reviews claim to determine how benefits/claims are to be paid, billed, collected, and adjudicated and adjust records as required;
4. processes internal and external referrals while ensuring appropriate coverage and documentation as necessary for coverage rules and guidelines;
5. obtains prior authorization or pre-certification to ensure billed claims will be covered under the appropriate insurance and respond to a variety of questions from health care providers, physicians, patients, insurance plan members, insurance companies, government representatives, and related interested parties in response to the status of requests, referrals, and claims;
6. counsels parents, patients, and students regarding plan eligibility, enrollment requirements, benefits, authorizations, referrals, and payments;
7. corresponds with managed care companies concerning the status of referrals and authorizations to adjudicate claims disputes.

DESCRIPTIONS OF LEVELS OF WORK

Under direct supervision, the Medical Insurance Representative functions in a training capacity and is assigned routine, non-complex medical/health claims, referrals, and prior authorizations.

A(n) Medical Insurance Representative typically -

1. for supervisor's review interprets codes or procedure(s) performed according to coding standards, which may require the interpretation and selection of the codes provided by or to the insurance carrier;
2. under direct supervision, reviews and analyzes itemized claims/bills or non-complex claim forms for consistency (i.e., ensures that services rendered by the physician or hospital are compatible with the diagnosis or treatment) and investigates discrepancies to determine the appropriate course of action required to accurately complete the claim processing, billing procedure, or adjudication process;
3. responds to a variety of questions from physicians, patients, hospitals, insurance companies, government agencies, and related interested parties concerning the status of medical bills, referrals, and prior authorizations;
4. corresponds with and responds to a variety of inquiries from health care providers, patients or plan members, insurance companies, government agencies, and related interested parties concerning the status of persons utilizing the services of a facility as required to identify, collect, and analyze the information to process simpler claim forms properly;
5. understands and applies basic medical terminology, coding, and billing and maintains an up-to-date understanding of billing and industry regulations;
6. reviews and analyzes routine payment, capitation, adjustment, or denial records and posts or adjusts records as required under the direct supervision of a supervisor.
7. serves as a liaison between insurance and providers to ensure coverage and benefits before treatment, acts as a patient advocate in securing and scheduling referrals, pre-authorizations, or pre-certifications;
8. under direct guidance from a supervisor, tracks, reports, and resolves simple third-party denials;
9. processes mail and correspondence identified to be a part of the billing and receivable function;
10. completes and submits payer-specific claim forms (paper, electronic, and other) and submits claim forms to payers through electronic billing systems, as required by the payer;
11. performs other related duties as assigned.

Under general supervision, the Medical Insurance Associate independently submits or takes the necessary actions to complete or process routine insurance claim/medical claim forms, referrals, and prior authorizations. They are also responsible for completing or processing moderately complex claim/medical forms, coordinating benefits between two or more third-party payers, and collecting outstanding payments. Employees at this level may train lower-level staff members.

A(n) Medical Insurance Associate typically -

1. takes the necessary action to complete, bill, collect or adjudicate moderately complex medical claims;
2. schedules internal referral appointments in the billing system per protocol;
3. posts and adjusts the benefits or financial files for persons utilizing the program;
4. interprets standard, established codes provided by the various agencies or healthcare providers and adjudicates procedures according to these interpretations;
5. reviews and analyzes itemized bills or claim forms for consistency and investigates discrepancies to determine the appropriate course of action required to complete the adjudication or billing process accurately;
6. trains Medical Insurance Representative and related support staff;
7. serves as a liaison between insurance and providers to ensure coverage and benefits before treatment, act as a patient advocate in securing and scheduling referrals, pre-authorizations, or pre-certifications;
8. assists in counseling patients, students, and parents about plan eligibility, benefits, and enrollment;
9. collects, reviews, and analyzes payment, capitation, adjustment, or denial records, and posts or adjusts records as required;
10. reviews billing data for accuracy and/or completeness and make the necessary corrections;
11. performs duties consistent with lower-level of series;
12. performs other related duties as assigned.

Under general supervision, the Medical Insurance Specialist independently takes the necessary action to complete, bill, collect, or adjudicate complex medical claims, referrals, and pre-certifications and serves as the unit's resource specialist for lower-level related clerical staff. Employees at this level work closely with other supervisors and staff to determine the day-to-day priorities and procedures maintain a high level of integrity within the unit. Employees at this level may supervise lower-level Medical Insurance staff and related clerical employees.

A(n) Medical Insurance Specialist typically -

1. takes the necessary action to complete, bill, collect or adjudicate all types of complex medical claims;
2. takes the necessary action to complete and responds to a variety of questions from lower-level Medical Insurance staff and related clerical support employees in regards to the billing, collecting, or adjudicating of medical claims;
3. reviews and analyzes insurance processing procedures to identify potential problem areas and develop a more streamlined processing procedure that increases efficiency while maintaining a high level of integrity within the unit;
4. assists with staff schedules interviewing, hiring, training, and evaluating lower-level staff;
5. compiles and composes activity reports that report a variety of statistics, including work efficiency measures, and that take into consideration the total volume of the unit;
6. acts as liaison with patients, plan members, healthcare providers, physicians, hospitals, insurance companies, government agencies, and related interested parties regarding problem claims, denials, and appeals;
7. counsels patients, students, and parents about plan eligibility, benefits, and enrollment;
8. performs duties consistent with the lower level of the series;
9. performs other related duties as assigned.

Under administrative direction, the Medical Insurance Assistant Manager plans, implements, and revises policies related to methods and procedures.

A(n) Medical Insurance Assistant Manager typically -

1. selects, trains, and supervises staff members; evaluates the work performance of staff and takes the appropriate disciplinary action as required;
2. develops, implements, interprets, revises, and enforces unit policies and procedures and assists with contracting or drafting benefits of the insurance plan(s);
3. determines the procedures that are to be followed in atypical circumstances;
4. responsible for implementing the compliance operations with all required accounting and auditing procedures, either through personal performance or the supervision of assigned staff;
5. advises and consults with campus personnel or other relevant individuals about policies related to medical insurance;
6. determines the adequacy of processing procedures;
7. responsible for the maintenance of records or record systems;
8. prepares reports as required;
9. corresponds with or makes direct calls regarding problem claims (i.e., responds to appeals);
10. performs duties consistent with the lower levels of the series;
11. performs other related duties as assigned.

Under administrative direction, the Medical Insurance Manager assists in developing and managing policies regarding manual and electronic claims processing, follow-up, referrals, prior authorizations, and funding management.

A(n) Medical Insurance Manager typically -

1. assists in managing staff and staff workloads; develops systems procedures and trains staff;
2. reads and understands payer contracts to identify proper reimbursement for the services provided;
3. conducts periodic reviews of business functions, both internal and external to the agency;
4. coordinates activities with external claims processing entities;
5. performs contract compliance reviews;
6. develops requests for proposals and requests for information for services;
7. writes requests for proposals, negotiates and contracts discount agreements for claims processing and eligibility services;
8. prepares written correspondences to insurance companies, attorneys, and patients or plan members to resolve disputes;
9. interprets federal, state, and agency rules and regulations;
10. develops and implements unit policies and procedures;
11. researches and resolves complex insurance claim issues;
12. conducts quality control reviews to ensure quality claim processing;
13. prepares, implements, and monitors the unit’s budget;
14. performs duties consistent with the lower levels of the series;
15. performs other related duties as assigned.

MINIMUM ACCEPTABLE QUALIFICATIONS

CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER

1. High school diploma or equivalent.
2. Any one or combination totaling six (6) 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 six (6) months
   2. Work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and/ or prior authorization.

KNOWLEDGE, SKILLS AND ABILITIES (KSAs)

1. Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluating customer satisfaction.
2. Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
3. Knowledge of basic medical terminology of basic hospital or physician billing, coding, referrals, and prior authorizations.
4. Knowledge of basic arithmetic with the ability to add, subtract, multiply and divide whole numbers, decimals and percentages.
5. Skill in using computers and computer systems (including hardware and software.
6. Ability to pay close attention to details and follow established procedures in completing work tasks.
7. Ability to maintain patient confidentiality following HIPAA guidelines and established policies and procedures.
8. Ability to convey routine, non-complex billing, claims, referrals, and prior authorization information to patients and staff.
9. Ability to work collaboratively, building strategic relations with colleagues, coworkers, constituents.

CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER

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.

KNOWLEDGE, SKILLS AND ABILITIES (KSAs)

1. Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluating customer satisfaction.
2. Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
3. Knowledge of medical terminology and hospital or physician billing, coding, referrals, and prior authorizations.
4. Knowledge of basic arithmetic with the ability to add, subtract, multiply and divide whole numbers, decimals and percentages.
5. Skill in using computers and computer systems (including hardware and software) to program, write, set up functions, enter data, or process information.
6. Ability to pay close attention to details and follow established procedures in completing work tasks.
7. Ability to maintain patient confidentiality following HIPAA guidelines and established policies and procedures.
8. Ability to convey moderately complex billing, claims, referral, and prior authorization information to patients and staff.
9. Ability to train others to work collaboratively, building strategic relations with colleagues, coworkers, constituents.

CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER

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.

KNOWLEDGE, SKILLS AND ABILITIES (KSAs)

1. Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluating customer satisfaction.
2. Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
3. Knowledge of complex medical terminology, hospital or physician billing and coding, referrals, and prior authorizations.
4. Knowledge of arithmetic with the ability to add, subtract, multiply and divide whole numbers, decimals and percentages.
5. Skill in evaluating information to determine compliance with standards. Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, standards and ensuring that lower-level employees are following standards.
6. Skill in using computers and computer systems (including hardware and software) to program, write, set up functions, enter data, or process information.
7. Ability to pay close attention to details, follow established procedures to complete work tasks and train others in those procedures.
8. Ability to maintain patient confidentiality following HIPAA guidelines and established policies and procedures.
9. Ability to train others and work collaboratively, building strategic relations with colleagues, coworkers, constituents.
10. Ability to plan, assign, and supervise the work of others.

CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER

1. Any one or combination totaling five (5) years (60 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)
      • Bachelor’s Degree (120 semester hours) equals three (3) years (36 months)
   2. Progressively more responsible work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and prior authorizations.

KNOWLEDGE, SKILLS AND ABILITIES (KSAs)

1. Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership techniques, production methods, and coordination of people and resources.
2. Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluating customer satisfaction.
3. Knowledge of laws, legal codes, court procedures, precedents, government regulations, executive orders, agency rules, and the democratic political process.
4. Extensive knowledge of medical insurance claims processing and Extensive knowledge of medical terminology, referrals, and prior authorizations.
5. Skill in evaluating information to determine compliance with standards. Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, standards and ensuring that lower-level employees are following standards.
6. Skill in personnel resources management through motivating, developing, and directing people as they work, identifying the best people for the job.
7. Skill in identifying the development needs of others and coaching, mentoring, or otherwise helping others improve their knowledge or skills.
8. Ability to train employees and plan, assign, and supervise the work of others.
9. Ability to work collaboratively, building strategic relations with colleagues, coworkers, constituents.
10. Ability to identify complex problems and review related information to develop and evaluate options and implement solutions.
11. Ability to use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
12. Ability to use good judgment and decision-making skills while considering potential actions' relative costs and benefits and choosing the most appropriate one.

CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER

1. Any one or combination totaling six (6) years (72 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)
      • Bachelor’s Degree (120 semester hours) equals three (3) years (36 months)
   2. Work experience in supervision or management or other positions of similar responsibility with experience in a healthcare environment working with medical claims, denials, rejections, referrals, and prior authorizations.

KNOWLEDGE, SKILLS AND ABILITIES (KSAs)

1. Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership techniques, production methods, and coordination of people and resources.
2. Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluating customer satisfaction.
3. Knowledge of laws, legal codes, court procedures, precedents, government regulations, executive orders, agency rules, and the democratic political process.
4. Extensive knowledge of medical insurance claims processing and Extensive knowledge of medical terminology, referrals, and prior authorizations.
5. Skill in evaluating information to determine compliance with standards. Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, standards and ensuring that lower-level employees are following standards.
6. Skill in personnel resources management through motivating, developing, and directing people as they work, identifying the best people for the job.
7. Skill in monitoring/assessing the performance of self, other individuals, or organizations to make improvements or take corrective action.
8. Skill in identifying the development needs of others and coaching, mentoring, or otherwise helping others improve their knowledge or skills.
9. Ability to train employees and plan, assign, and supervise the work of others.
10. Ability to work collaboratively, building strategic relations with colleagues, coworkers, constituents.
11. Ability to identify complex problems and review related information to develop and evaluate options and implement solutions.
12. Ability to use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
13. Ability to use good judgment and decision-making skills while considering potential actions' relative costs and benefits and choosing the most appropriate one.