Utilization Management Specialist – Prior Authorization

🕒 July 28

🌾 North Dakota – Remote

🌾 North Dakota – Remote

💵 $27 - $38 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

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👻 Ghost score 36%

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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

• Conduct level-of-care and medical-necessity reviews within patient medical records • Perform utilization management activities in accordance with the UM plan and accreditation/regulatory requirements • Complete and coordinate implementation, evaluation, and improvement of utilization management and prior authorization processes • Determine medical necessity, authorization, and continued-stay reviews • Perform diagnosis and procedural coding for working DRG assignments • Review patient charts and assist with insurance coverage, denials, prior authorizations, scheduled procedures, same-day readmissions, and length-of-stay matters • Validate the appropriate level of care for pre-admission surgical reviews • Apply InterQual criteria to assess appropriateness of services and control costs • Refer cases requiring secondary review or escalation • Collaborate with healthcare teams, physicians, and clinical professionals to promote medically necessary resource utilization and documentation improvement • Educate healthcare teams about utilization trends, external regulations, internal policies, and prior authorization • Monitor resource utilization, risk management, and quality of care • Prepare reports and correspondence and maintain appropriate records • Ensure compliance with professional standards, NCD/LCD, CMS, and state and federal regulations • Assist with special projects, initiatives, organizational goals, and audits • Provide guidance, training, and answers to team members as a resource and point of contact • Adapt scheduling as communication needs across departments and clinical units fluctuate

🎯 Requirements

• Graduate from a nationally accredited nursing program required, including CCNE, ACEN, or NLN CNEA accreditation • Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing • Required department-specific competencies and certifications must be obtained and maintained • Bachelor's degree in nursing preferred • Ability to conduct utilization management and prior authorization reviews • Knowledge of InterQual clinical decision support criteria • Knowledge of diagnosis and procedural coding for working DRG assignments • Knowledge of NCD/LCD, CMS, and state and federal regulatory requirements • Working knowledge of payer standards for utilization management authorization requirements • Dynamic and tactful interpersonal skills when relating to physicians and healthcare professionals • Ability to work day shift and 40 hours per week

🏖️ Benefits

• Home-based/remote work opportunity • 40 scheduled weekly hours • EEO/AA protections • Disability accommodation support for online application