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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.
Facility: Cherapa Place Building
Location:Sioux Falls, SD
Address: 300 N Cherapa Pl, Sioux Falls, SD 57103, USA
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40. 00
Salary Range: $18.00 - $29.00
Department Details
Possible work from home option after training
Job Summary
Responsible for accurate coordination of documentation, interpretation of policies, and handling of correspondence related to denials and appeals submitted by providers and members. Must administer benefits in accordance within appropriate regulatory timelines dependent on each product line. Administer and prioritize daily tasks, and apply Sanford Health Plan policies and regulatory requirements consistently and use good judgment as when to seek out guidance. Possess broad understanding of products and benefits and a demonstrated understanding of regulatory requirements and timeframes.
Intake and coordinate appeals and Denials, and then make determinations based on member policy documents, and/or medical criteria guidelines. Communicate determinations with members, providers and third parties regarding status.
Conduct review of denials within required timeframes utilizing policy criteria sets, knowledge of payor regulations, and considerable judgment, to determine appropriateness of care.
Triage appeals and Denials to meet the needs of urgent requests, both over the phone through the mail. Routinely communicate and collaborate with internal and external constituents about highly escalated issues.
May be required to perform medical necessity reviews, when needed, to make the determinations on policies.
Demonstrate strong communications skills, both on the phone and in writing, with a strong understanding of medical terminology and a high level of attention to detail.
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, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
One (1) year experience required in appeals, medical necessity, or prior authorization process.
If a graduate of a nursing program, 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 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.
Req Number: R-0178233
Job Function: Revenue Cycle
Featured: No
