Senior Appeal and Denial Specialist - Remote NE
Good Samaritan Society, Sanford, Florida, United States, 32771
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.
Facility:
Remote NE (Central Time) Location:
Remote, NE Address: Shift:
8 Hours - Day Shifts Job Schedule:
Full time Weekly Hours:
40.00 Salary Range:
$21.50 - $34.50 Department Details Remote or Hybrid option Job Summary
Facilitates the denial and appeal process through exercising clinical expertise and reviewing medical records for medical necessity and policy requirements. Responsible for leveraging clinical knowledge and standard procedures to track appeals through first, second, and subsequent levels, and ensuring timely filing of appeals as required by contracts and regulations. Promotes departmental awareness of clinical best practices. Administers and prioritizes daily tasks, applies Sanford Health Plan policies and regulatory requirements consistently, and uses sound judgment when to seek guidance. Possesses a broad understanding of products and benefits and a demonstrated understanding of regulatory requirements and timeframes. Acquires deep knowledge of product network requirements and makes case decisions accordingly. Contributes to the establishment of best practices for audit and compliance. Ensures compliance with current government and industry audit practices and requirements. Conducts reviews of clinical-based denials (e.g., Medical Necessity, Level of Care) within required timeframes using clinical criteria, knowledge of payor regulations, and sound clinical judgment to determine appropriateness of care. Coaches patients and families on proactive management of their own care. Consults on identifying and resolving common barriers to patient progress. Establishes shared goals to foster collaboration. Delivers written and oral communication, responds to questions and concerns, and achieves specific outcomes and impact. Demonstrates in-depth knowledge of the organization\'s policies and practices requiring confidentiality. Implements tactics to de-escalate problem situations. Delegates appropriate levels of responsibility and authority. Communicates well downward, upward, and outward. Anticipates changing business situations, adjusts priorities, and gathers necessary resources to achieve goals. Exchanges private healthcare information with other facilities, such as insurance companies and pharmacies, in compliance with regulations. Demonstrates experience working with multiple healthcare organizations or providers. Applies policies and procedures designed to ensure compliance with policies and ethical codes. Collaborates and communicates with all departments of a healthcare organization for preparation for external audits. Mentors others in their technical areas and shares expertise on critical issues. Responds to shifting priorities while maintaining progress of regularly scheduled work. Implements effective medical case management strategies. Adapts language, tone, structure, and level of detail to the needs of others. Uses varying problem-solving approaches and techniques as appropriate. Streamlines the critical workflow for executing key processes. Promotes understanding of multiple product and service groups and their interdependencies. Qualifications
Bachelor’s degree required, or a combination of applicable degree completion and applicable experience will be considered. Graduate from a nationally accredited nursing program preferred, including, but not limited to, CCNE, ACEN, and NLN CNEA. Three (3) years of experience required in appeals, medical necessity, or prior authorization process. If a nursing graduate, currently licensed with the applicable State Nursing Board and/or possess multistate licensure privileges as required by position. 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, dental, and vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package. 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 email 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. Additional Information
Req Number:
R-0248875 Job Function:
Revenue Cycle Featured:
No
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Remote NE (Central Time) Location:
Remote, NE Address: Shift:
8 Hours - Day Shifts Job Schedule:
Full time Weekly Hours:
40.00 Salary Range:
$21.50 - $34.50 Department Details Remote or Hybrid option Job Summary
Facilitates the denial and appeal process through exercising clinical expertise and reviewing medical records for medical necessity and policy requirements. Responsible for leveraging clinical knowledge and standard procedures to track appeals through first, second, and subsequent levels, and ensuring timely filing of appeals as required by contracts and regulations. Promotes departmental awareness of clinical best practices. Administers and prioritizes daily tasks, applies Sanford Health Plan policies and regulatory requirements consistently, and uses sound judgment when to seek guidance. Possesses a broad understanding of products and benefits and a demonstrated understanding of regulatory requirements and timeframes. Acquires deep knowledge of product network requirements and makes case decisions accordingly. Contributes to the establishment of best practices for audit and compliance. Ensures compliance with current government and industry audit practices and requirements. Conducts reviews of clinical-based denials (e.g., Medical Necessity, Level of Care) within required timeframes using clinical criteria, knowledge of payor regulations, and sound clinical judgment to determine appropriateness of care. Coaches patients and families on proactive management of their own care. Consults on identifying and resolving common barriers to patient progress. Establishes shared goals to foster collaboration. Delivers written and oral communication, responds to questions and concerns, and achieves specific outcomes and impact. Demonstrates in-depth knowledge of the organization\'s policies and practices requiring confidentiality. Implements tactics to de-escalate problem situations. Delegates appropriate levels of responsibility and authority. Communicates well downward, upward, and outward. Anticipates changing business situations, adjusts priorities, and gathers necessary resources to achieve goals. Exchanges private healthcare information with other facilities, such as insurance companies and pharmacies, in compliance with regulations. Demonstrates experience working with multiple healthcare organizations or providers. Applies policies and procedures designed to ensure compliance with policies and ethical codes. Collaborates and communicates with all departments of a healthcare organization for preparation for external audits. Mentors others in their technical areas and shares expertise on critical issues. Responds to shifting priorities while maintaining progress of regularly scheduled work. Implements effective medical case management strategies. Adapts language, tone, structure, and level of detail to the needs of others. Uses varying problem-solving approaches and techniques as appropriate. Streamlines the critical workflow for executing key processes. Promotes understanding of multiple product and service groups and their interdependencies. Qualifications
Bachelor’s degree required, or a combination of applicable degree completion and applicable experience will be considered. Graduate from a nationally accredited nursing program preferred, including, but not limited to, CCNE, ACEN, and NLN CNEA. Three (3) years of experience required in appeals, medical necessity, or prior authorization process. If a nursing graduate, currently licensed with the applicable State Nursing Board and/or possess multistate licensure privileges as required by position. 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, dental, and vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package. 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 email 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. Additional Information
Req Number:
R-0248875 Job Function:
Revenue Cycle Featured:
No
#J-18808-Ljbffr