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Role Description

This position 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, ensuring timely filing of appeals as required by contracts and regulations, and promoting departmental awareness of clinical best practices.

• Administer and prioritize daily tasks, applying Sanford Health Plan policies and regulatory requirements consistently.
• Possess broad understanding of products and benefits and a demonstrated understanding of regulatory requirements and timeframes.
• Acquire deep knowledge of product network requirements and make case decisions accordingly.
• Contribute to the establishment of best practices for audit and compliance.
• Ensure compliance with current government and industry audit practices and requirements.
• Conduct review of clinical-based denials (i.e. Medical Necessity, Level of Care) within required timeframes utilizing clinical criteria sets and considerable clinical judgment.
• Coach patients and families on how to be proactive in managing their own care.
• Consult on the process for identifying and resolving common barriers to patient progress.
• Establish shared goals to foster collaboration.
• Deliver written and oral communication, respond to questions and concerns, and produce specific outcomes and impact.
• Demonstrate in-depth knowledge of organization's policies and practices requiring confidentiality.
• Implement tactics to de-escalate problem situations immediately.
• Delegate appropriate levels of responsibility and authority.
• Communicate well downward, upward, and outward.
• Anticipate changing business situations, adjust priorities accordingly, and gather necessary resources to achieve the goal.
• Exchange private healthcare information with other facilities according to regulations.
• Demonstrate experience working with multiple healthcare organizations or providers.
• Apply policies and procedures designed to ensure compliance with policies and ethical codes.
• Collaborate and communicate with all departments of a healthcare organization for the preparation for external audits.
• Mentor others in their technical areas and share expertise on critical issues.
• Respond to shifting priorities while maintaining progress of regularly scheduled work.
• Implement effective medical case management strategies.
• Adapt language, tone, structure, and level of detail to the needs of others.
• Use varying problem-solving approaches and techniques as appropriate.
• Streamline the critical workflow for executing key processes.
• Promote 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 graduate of a nursing program, currently licensed with the applicable State Nursing Board and/or possess multistate licensure privileges as required by position.

Company Description

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.