Utilization Management Specialist – Prior Authorization

🕒 July 16

🌾 North Dakota, Minnesota, +1 more states – Remote

🌾 North Dakota – Remote ❄️ Minnesota – Remote 🗿 South Dakota – Remote

💵 $27 - $38 / hour

⏱ Part Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 45%

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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 medical necessity reviews within patient medical records • Perform utilization management activities in accordance with the UM plan and accreditation/regulatory requirements • Complete and coordinate activities related to UM and prior authorization processes • Determine medical necessity, authorization, continued-stay review, diagnosis, and procedural coding for working DRG assignments • Review patient charts, insurance coverage and denials, prior authorizations, scheduled procedures, same-day readmissions, and length of stay • Validate appropriate level of care for pre-admission surgical reviews • Apply InterQual clinical decision support criteria • Escalate cases requiring secondary review when departmental standards are not met • Collaborate with healthcare team members, physicians, and clinical professionals on resource utilization and documentation improvement • Educate healthcare team members on trends, regulations, policies, and resource utilization • 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 regulatory requirements • Maintain working knowledge of payer standards for utilization management authorization requirements • Assist with special projects, initiatives, organizational goals, and audits • Serve as a resource and point of contact for guidance, training, and questions • Adapt scheduling to communication needs across interdepartmental and clinical units

🎯 Requirements

• Graduate from a nationally accredited nursing program required, including CCNE, ACEN, or 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 • Knowledge of oncology is preferred