Senior Appeal and Denial Specialist

Job not on LinkedIn

🔥 9 minutes ago

🗿 South Dakota, Wisconsin – Remote

🗿 South Dakota – Remote 🧀 Wisconsin – Remote

💵 $21 - $34 / hour

⏰ Full Time

🟠 Senior

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Sanford Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1894

🛡️ Insurance

🏥 Healthcare

⚕️ Healthcare Insurance

Insurance • Healthcare • Healthcare Insurance

Sanford Health is the largest rural health system in the United States, dedicated to transforming the healthcare experience and providing access to world-class healthcare in America's heartland. Headquartered in Sioux Falls, South Dakota, Sanford Health serves over 1. 4 million patients and nearly 200,000 health plan members across 250,000 square miles. The integrated health system includes 48 medical centers, 211 clinic locations, and more than 160 senior living centers, employing 2,900 physicians and advanced practice providers. Sanford Health is committed to offering compassionate care through its Centers of Excellence, focusing on specialties such as cancer, orthopedics, women’s health, and genetics. Additionally, it provides affordable health insurance, engages in extensive clinical trials, and supports personalized genetic medicine.

📋 Description

• Facilitate the denial and appeal process by reviewing medical records for medical necessity and policy requirements. • Track appeals through first, second, and subsequent levels and ensure timely filing according to contracts and regulations. • Administer and prioritize daily tasks while applying Sanford Health Plan policies and regulatory requirements. • Make case decisions based on product network requirements. • Contribute to audit and compliance best practices and ensure compliance with government and industry requirements. • Review clinical-based denials within required timeframes using clinical criteria, payor regulations, and clinical judgment. • Coach patients and families on proactive care management and help identify and resolve barriers to patient progress. • Communicate with patients, families, departments, insurance companies, pharmacies, and other healthcare organizations. • Prepare for external audits and collaborate across healthcare departments. • Mentor others, share technical expertise, implement medical case management strategies, streamline workflows, and promote understanding of products and services.

🎯 Requirements

• 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 CCNE, ACEN, and 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. • Understanding of Sanford Health Plan policies, regulatory requirements, products, benefits, product network requirements, payor regulations, clinical criteria sets, audit practices, and healthcare compliance requirements. • Experience working with multiple healthcare organizations or providers. • Ability to handle confidential information and exchange private healthcare information according to regulations. • Ability to mentor others, adapt communication to different audiences, manage shifting priorities, and apply problem-solving approaches.

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