Sanford Health
Careers With Purpose
Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We’re proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.
Job Details
Facility: Remote SD (Central Time)
Location: Remote, SD
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40.00
Salary Range: $24.00 - $38.50
Department Details: This position may be hybrid or remote
Job Summary Responsible for performing advanced level work related to appeals and denials by conducting a comprehensive review of clinical documentation, writing compelling arguments based on the clinical documentation, and interpreting medical policies.
Responsibilities
Lead appeals and denial specialist role, providing management support when the manager is unavailable and leading process improvement initiatives.
Maintain subject matter expertise, identify resources, and support processes for the appeal and denial team.
Serve as the go-to source for complex questions and issues and lead team meetings.
Utilize quality assurance tools, techniques, and standards to ensure compliance with audit and compliance best practices.
Conduct reviews of clinical-based denials (e.g., Medical Necessity, Level of Care) within required timeframes using clinical criteria sets and payor regulations.
Coach patients and families on proactive care management and consult to resolve common barriers to patient progress.
Deliver written and oral communication, respond to questions, and produce specific outcomes and impact.
Demonstrate in-depth knowledge of confidential policies, implement de-escalation tactics, delegate responsibilities, and communicate effectively at all levels.
Anticipate changing business situations, adjust priorities, and gather necessary resources for goal achievement.
Exchange private healthcare information with insurance companies and pharmacies according to regulations.
Collaborate with all departments for external audits, mentor others, and share expertise on critical issues.
Respond to shifting priorities while maintaining progress of scheduled work and implement effective medical case management strategies.
Streamline critical workflow for executing key processes and adapt language, tone, and structure to audience needs.
Use problem‑solving approaches and techniques appropriate to situations, ensuring tasks are handled and prioritized effectively.
Apply Sanford Health Plan policies and regulatory requirements consistently, seeking guidance when needed.
Perform medical necessity reviews when required to determine policy applicability.
Qualifications
Bachelor’s degree required, or a combination of degree and applicable experience considered.
Graduate from a nationally accredited nursing program preferred (CCNE, ACEN, NLN CNEA).
Five (5) years experience required in appeals, medical necessity, or prior authorization processes.
Experience with regulatory programs and data reporting preferred.
If a nursing graduate, currently licensed with the applicable State Nursing Board and/or possesses multi-state licensure privileges.
Benefits Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home‑work balance. For more information about Total Rewards, visit https://sanfordcareers.com/benefits.
Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to talent@sanfordhealth.org .
Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment.
Job Requirements
Req Number: R-0243650
Job Function: Revenue Cycle
Featured: No
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Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We’re proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.
Job Details
Facility: Remote SD (Central Time)
Location: Remote, SD
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40.00
Salary Range: $24.00 - $38.50
Department Details: This position may be hybrid or remote
Job Summary Responsible for performing advanced level work related to appeals and denials by conducting a comprehensive review of clinical documentation, writing compelling arguments based on the clinical documentation, and interpreting medical policies.
Responsibilities
Lead appeals and denial specialist role, providing management support when the manager is unavailable and leading process improvement initiatives.
Maintain subject matter expertise, identify resources, and support processes for the appeal and denial team.
Serve as the go-to source for complex questions and issues and lead team meetings.
Utilize quality assurance tools, techniques, and standards to ensure compliance with audit and compliance best practices.
Conduct reviews of clinical-based denials (e.g., Medical Necessity, Level of Care) within required timeframes using clinical criteria sets and payor regulations.
Coach patients and families on proactive care management and consult to resolve common barriers to patient progress.
Deliver written and oral communication, respond to questions, and produce specific outcomes and impact.
Demonstrate in-depth knowledge of confidential policies, implement de-escalation tactics, delegate responsibilities, and communicate effectively at all levels.
Anticipate changing business situations, adjust priorities, and gather necessary resources for goal achievement.
Exchange private healthcare information with insurance companies and pharmacies according to regulations.
Collaborate with all departments for external audits, mentor others, and share expertise on critical issues.
Respond to shifting priorities while maintaining progress of scheduled work and implement effective medical case management strategies.
Streamline critical workflow for executing key processes and adapt language, tone, and structure to audience needs.
Use problem‑solving approaches and techniques appropriate to situations, ensuring tasks are handled and prioritized effectively.
Apply Sanford Health Plan policies and regulatory requirements consistently, seeking guidance when needed.
Perform medical necessity reviews when required to determine policy applicability.
Qualifications
Bachelor’s degree required, or a combination of degree and applicable experience considered.
Graduate from a nationally accredited nursing program preferred (CCNE, ACEN, NLN CNEA).
Five (5) years experience required in appeals, medical necessity, or prior authorization processes.
Experience with regulatory programs and data reporting preferred.
If a nursing graduate, currently licensed with the applicable State Nursing Board and/or possesses multi-state licensure privileges.
Benefits Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home‑work balance. For more information about Total Rewards, visit https://sanfordcareers.com/benefits.
Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to talent@sanfordhealth.org .
Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment.
Job Requirements
Req Number: R-0243650
Job Function: Revenue Cycle
Featured: No
#J-18808-Ljbffr