Senior Appeal and Denial Specialist Remote NE
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Job Location:
Sioux Falls, SD - USA
Monthly Salary:
$ 21 - 34
Posted on:
7 hours ago
Vacancies:
1 Vacancy
Job Summary
Sanford Health is one of the largest and fastest-growing not-for-profit 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: $21.50 - $34.50Union Position:
NoDepartment Details
Remote or Hybrid optionSummary
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 practicesJob 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 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 organizations 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
Bachelors 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) years 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- or send an email to
Required Experience:
Senior IC
Key Skills
- Computer Hardware
- Mac Os
- Manufacturing & Controls
- Root cause Analysis
- Windows
- Customer Support
- Remote Access Software
- Operating Systems
- Encryption
- Remedy
- Chemistry
- Cerner
About Company
Marshfield Clinic is a health care system with over 50 locations in northern, central, and western Wisconsin. Marshfield Clinic Don't just live. Shine.
