Senior Appeal and Denial Specialist - Remote SD
Good Samaritan Society, Sanford, Florida, United States, 32771
Overview
Careers With Purpose Sanford Health
is one of the largest and fastest-growing not-for-profit health systems in the United States. We offer development and advancement opportunities to our nearly 50,000 members dedicated to health and healing across our footprint. Facility:
Remote SD (Central Time) Location:
Remote, SD 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 clinical review of medical records for medical necessity and policy requirements. Tracks appeals through first, second, and subsequent levels and ensures timely filing as required by contracts and regulations. Promotes departmental awareness of clinical best practices. Administers and prioritizes daily tasks in accordance with Sanford Health Plan policies and regulatory requirements. Demonstrates broad understanding of products and benefits and a working knowledge of regulatory timeframes and product network requirements to inform case decisions. Contributes to the establishment of best practices for audit and compliance, and ensures compliance with current government and industry audit practices and requirements. Conducts reviews of clinical denials (e.g., Medical Necessity, Level of Care) within required timeframes to determine appropriateness of care using clinical criteria and payor regulations. Coaches patients and families on proactive care management and resolves common barriers to progress. Delivers written and oral communication, responds to questions and concerns, and achieves specified outcomes. Demonstrates knowledge of organizational policies requiring confidentiality. Implements tactics to de-escalate problem situations, delegates appropriately, and communicates effectively on multiple levels. Anticipates changing business needs, adjusts priorities, and coordinates resources. Maintains compliance with privacy regulations when exchanging private healthcare information with insurers and pharmacies. Collaborates with multiple healthcare organizations or providers and applies policies to ensure ethical conduct. Collaborates with all departments for external audits, mentors others in technical areas, and responds to shifting priorities while maintaining progress on regular work. Applies medical case management strategies and adapts communication style to needs of others. Streamlines workflows and promotes understanding of product and service 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 CCNE, ACEN, or NLN CNEA. Three (3) years' experience required in appeals, medical necessity, or prior authorization processes. If a graduate of a nursing program, currently licensed with the applicable State Nursing Board and/or possess multistate licensure privileges as required by the position.
Benefits
Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, benefits include health, dental, vision, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous paid time off package. For more information about Total Rewards, visit SanfordCareers.com/benefits. Sanford is an EEO/AA Employer M/F/Disability/Vet. If you need accommodation for the online application, 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.
Other
Req Number:
R-0248874 Job Function:
Revenue Cycle Featured:
No
#J-18808-Ljbffr
Careers With Purpose Sanford Health
is one of the largest and fastest-growing not-for-profit health systems in the United States. We offer development and advancement opportunities to our nearly 50,000 members dedicated to health and healing across our footprint. Facility:
Remote SD (Central Time) Location:
Remote, SD 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 clinical review of medical records for medical necessity and policy requirements. Tracks appeals through first, second, and subsequent levels and ensures timely filing as required by contracts and regulations. Promotes departmental awareness of clinical best practices. Administers and prioritizes daily tasks in accordance with Sanford Health Plan policies and regulatory requirements. Demonstrates broad understanding of products and benefits and a working knowledge of regulatory timeframes and product network requirements to inform case decisions. Contributes to the establishment of best practices for audit and compliance, and ensures compliance with current government and industry audit practices and requirements. Conducts reviews of clinical denials (e.g., Medical Necessity, Level of Care) within required timeframes to determine appropriateness of care using clinical criteria and payor regulations. Coaches patients and families on proactive care management and resolves common barriers to progress. Delivers written and oral communication, responds to questions and concerns, and achieves specified outcomes. Demonstrates knowledge of organizational policies requiring confidentiality. Implements tactics to de-escalate problem situations, delegates appropriately, and communicates effectively on multiple levels. Anticipates changing business needs, adjusts priorities, and coordinates resources. Maintains compliance with privacy regulations when exchanging private healthcare information with insurers and pharmacies. Collaborates with multiple healthcare organizations or providers and applies policies to ensure ethical conduct. Collaborates with all departments for external audits, mentors others in technical areas, and responds to shifting priorities while maintaining progress on regular work. Applies medical case management strategies and adapts communication style to needs of others. Streamlines workflows and promotes understanding of product and service 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 CCNE, ACEN, or NLN CNEA. Three (3) years' experience required in appeals, medical necessity, or prior authorization processes. If a graduate of a nursing program, currently licensed with the applicable State Nursing Board and/or possess multistate licensure privileges as required by the position.
Benefits
Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, benefits include health, dental, vision, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous paid time off package. For more information about Total Rewards, visit SanfordCareers.com/benefits. Sanford is an EEO/AA Employer M/F/Disability/Vet. If you need accommodation for the online application, 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.
Other
Req Number:
R-0248874 Job Function:
Revenue Cycle Featured:
No
#J-18808-Ljbffr