Key Facts

Remote From:

Full time

Senior (5-10 years)

English

Hard Skills

Appeals Language Interpretation Insurance Regulatory Law Medical Necessity Government Compliance Auditing Auditing Protected Health Information Health Policies Policy Enforcement Utilization Management Case Management Systems Clinical Assessments Process Management Resource Management Medication Dispensation Process Improvement Cross-Functional Collaboration Online Communication De-escalation Techniques

Other Skills

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Quality Assurance
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Decision Making
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Delegation Skills
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Client Confidentiality
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Non-Verbal Communication
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Adaptability
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Leadership
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Time Management
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Complex Problem Solving
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Critical Thinking
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Mentorship
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Social Skills

Roles & Responsibilities

Graduate from a nationally accredited nursing program (CCNE, ACEN, NLN CNEA) required
Bachelor's degree in nursing preferred
Three years of related experience required; current unencumbered RN license with the State Board of Nursing
Certified Professional in Healthcare Quality (CPHQ) preferred

Requirements:

Lead the appeals and denials process, performing advanced case reviews, applying clinical criteria and payer regulations, and ensuring quality assurance across the workflow
Provide leadership and case oversight; mentor staff, coordinate cross-departmental collaboration, and assist the supervisor with QA and accreditation monitoring
Identify and implement process improvements, develop best practices for audits/compliance, and support preparation for external audits in collaboration with other departments
Serve as a subject-matter expert for complex questions, communicate effectively (written and oral), de-escalate issues, and ensure compliance with policies and confidentiality

Sanford Health

About Sanford Health

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. Headquartered in Sioux Falls, South Dakota, the organization serves more than one million patients and 220,000 health plan members across 250,000 square miles. The integrated health system has 47 medical centers, 2,800 Sanford physicians and advanced practice providers, 170 clinical investigators and research scientists, more than 200 Good Samaritan Society senior care locations and world clinics in 8 countries around the globe. Learn more about Sanford Health's commitment to shaping the future of rural health care across the lifespan at sanfordhealth.org or Sanford Health News.

Company type: Large

Founded: 2018

Company size: 10001

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Job description

Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We’re proud to offer many development and advancement opportunities to our nearly 50,000 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:

Salary Range: $29.00 - $46.50

Union Position:

Department Details

This position is able to be remote!

Summary

The Lead UM Specialist will perform advanced level work related to appeals and denials, provide leadership, case oversight, interpretation of medical policy, workflow coordination, and quality assurance across the appeals process. Works to develop process improvement initiatives, problem solving complex tasks, collaborate with multiple departments, and responsible for assisting the supervisor in quality assurance and accreditation monitoring.

Job Description

Maintains a high level of subject matter expertise and possesses the ability to identify resources and support processes for the appeal and denial team. Utilizes complex thinking skills to review the entirety of a case and implement necessary clinical criteria and payer regulations. Serves as the go to source for complex questions and issues. Displays strong leadership skills. Exhibits the ability to take initiative and set a strong example within own function. Demonstrates expertise in quality assurance tools, techniques and standards. Displays strong personal commitment to organizational success, inspiring others to commit to shared goals. Works cooperatively and capably with a wide variety of people. Ensures that written message is understood as intended. 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 care. 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 organization's 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. Essential functions must occur simultaneously; therefore, the employee must be able to appropriately handle and prioritize various daily tasks. The employee must have the ability to learn and apply Sanford Health Plan policies and regulatory requirements consistently and the judgment to seek out guidance as needed. May be required to perform medical necessity reviews, when needed, to make the determinations on policies.

Qualifications

Bachelor's 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).

Three years of related experience required.

Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing. Certified Professional in Healthcare Quality preferred. 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 call 1-877-673-0854 or send an email to talent@sanfordhealth.org.