Utilization Management Specialist
Utilization Management Specialist
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$ 24 - 38
1 Vacancy
Job Description
Sanford Health is one of the largest and fastestgrowing notforprofit health systems in the United States. Were proud to offer many development and advancement opportunities to our nearly 50000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.
Work Shift:
8 Hours Day Shifts (United States of America)Scheduled Weekly Hours:
40Salary Range: $24.00 $38.50Union Position:
NoDepartment Details
Monday through Friday 8 am to 5 pm. No holidays or weekends.Summary
Conduct level of care medical necessity reviews within patients medical records. Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements. Completes/coordinates activities relating to the implementation ongoing evaluation and improvements to UM and/or prior authorization processes with applicable. Completes activities relating to determination of medical necessity authorization continued stay review including diagnosis and procedural coding for working diagnosis related group (DRG) assignments.Job Description
Workflows may include patient chart review and assisting with and managing of insurance coverage and denials prior authorizations scheduled procedures sameday readmission reviews as well as length of stay. Ensure validation of appropriate level of care for preadmission surgical reviews prior to admission. Reviews include InterQual clinical decision support criteria to ensure both the appropriateness of medical services and effective cost control. Ability to determine appropriate action for referring cases that do not meet departmental standards and require additional secondary review and/or escalation as needed.
May also be actively involved in collaborating with members of the healthcare team to promote medically necessary resource utilization and achievement of fiscal outcomes when appropriate. Collaborates with physicians and other clinical professionals as needed to assist in documentation improvement practices for effective and appropriate services. Dynamic and tactful interpersonal skills particularly in relating to physicians and other health care professionals. Educates members of the healthcare team regarding trends external regulations and internal policies that effect resource utilization and potentially prior authorization.
Assists the department in monitoring the utilization of resources risk management and quality of care for patients in accordance with guidelines and criteria. Assist in report preparation correspondence and maintenance of appropriate records. Ensure services comply with professional standards national and local coverage determinations (NCD/LCD) centers for Medicare and Medicaid services (CMS) as well as state and federal regulatory requirements. Maintain working knowledge of payer standards for UM functions for authorization requirements.
May assist with additional special projects related to work upcoming initiatives new organizational goals and audits when delegated. Considered a resource to all team members and acts as a point of contact for guidance training and assisting with questions. Demonstrate flexibility and adaptability where scheduling may fluctuate due to communication needs within interdepartmental and clinical units are required.
Qualifications
Bachelors degree in nursing preferred. Graduate from a nationally accredited nursing program required 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).Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing. Obtains and subsequently maintains required department specific competencies and certifications.
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 callor send an email to
Required Experience:
Unclear Seniority
Employment Type
Full-Time
