Senior Appeal and Denial Specialist

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland.

Work Shift:

8 Hours - Day Shifts (United States of America)

Scheduled Weekly Hours:

40

Compensation:

Salary Range: $21.50 - $34.50

Union Position:

No

Department Details

Fully Remote Position

Summary

Facilitates the denial and appeal process through exercising clinical expertise and clinical by 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, in addition to promoting departmental awareness of clinical best practices

Job Description

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. Acquire a deep knowledge of product network requirements and make 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.

Conduct review of clinical-based denials (i.e. Medical Necessity, Level of Care) within required timeframes utilizing clinical criteria sets, knowledge of payor regulations, and considerable clinical judgment, to determine appropriateness of care.

Coaches patients and families on how to be proactive in managing their own care. Consults on the process for identifying and resolving common barriers to patent progress. Establishes shared goals to foster collaboration. Delivers written and oral communication, responds to questions and concerns, and produce specific outcomes and impact.

Demonstrates in-depth knowledge of organization's policies and practices requiring confidentiality. Implements tactics to de-escalate problem situations immediately. Delegates appropriate levels of responsibility and authority. Communicates well downward, upward, and outward. Anticipates changing business situations, adjusts priorities accordingly and gathers necessary resources to achieve the goal. Exchanges private healthcare information with other facilities, such as insurance companies and pharmacies, according to 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 the 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, 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).

Three (3) year's 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.

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 1-877-949-5678 or send an email to talent@sanfordhealth.org.

The Sanford organization owns and manages multiple distinct brands, including Sanford Health, Marshfield Clinic, and Good Samaritan, as well as Lewis Drug, Sanford Health Equip, Solutions by Sanford, Great Shots, and Blue Rock Bar & Grill.

About Sanford Health

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. Headquartered in Sioux Falls, South Dakota, the organization has 53,000 employees and serves over 2 million patients and nearly 425,000 health plan members across the upper Midwest including South Dakota, North Dakota, Minnesota, Wyoming, Iowa, Wisconsin and the Upper Peninsula of Michigan. The integrated nonprofit health system includes a network of 56 hospitals, 288 clinic locations, 147 senior care communities, 4,000 physicians and advanced practice providers and nearly 1,500 active clinical trials and studies. The organization’s transformational virtual care initiative brings patients closer to care with access to 78 specialties. Learn more about Sanford Health’s commitment to shaping the future of rural health care across the lifespan at sanfordhealth.org or Sanford Health News.

About Good Samaritan

Good Samaritan, one of the nation’s largest nonprofit providers of senior care and services, is committed to transforming the aging experience through innovation, compassion and personalized care. As part of Sanford Health, an integrated nonprofit health system headquartered in Sioux Falls, South Dakota, Good Samaritan serves 10,000 seniors and offers access to a full continuum of care, including 94 rehabilitation and skilled nursing centers, 56 assisted living and memory care facilities, 44 independent living locations and 37 home health and hospice agencies. The senior care provider delivers services across the upper Midwest, with 70% of residents living in rural communities. Learn more about Good Samaritan’s mission and commitment to delivering high quality senior care in rural America at good-sam.com.