Key Facts

Remote From:

Full time

English

Hard Skills

Utilization Management Prior Authorization Medical Necessity Perioperative Care Documentation Generation Nurse Licensure Compact Regulatory Compliance Clinical Informatics Escalation Procedures Resource Monitor Evaluation Of Care Patient Progress Notes Clinical Research Coordination Insurance Follow-Up Risk Management Operational Process Reviews Auditing Privileged Access Management

Other Skills

•
Decision Making
•
Communication
•
Adaptability
•
Tactfulness
•
Time Management
•
Teamwork
•
Critical Thinking
•
Detail Oriented
•
Mentorship
•
Social Skills

Roles & Responsibilities

Bachelor's degree in nursing preferred.
Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing.
Graduate from a nationally accredited nursing program (e.g., CCNE, ACEN, NLN CNEA) required.
Obtains and maintains required department-specific competencies and certifications.

Requirements:

Conduct level-of-care medical necessity reviews within patient charts and perform utilization management activities to determine medical necessity, authorize services, and conduct continued stay reviews, including DRG coding as needed.
Review workflows such as chart reviews, insurance coverage and denials, prior authorizations, scheduled procedures, same-day readmission reviews, and length-of-stay determinations.
Collaborate with physicians and the healthcare team to promote medically necessary resource utilization, assist in documentation improvement, and educate team on trends, regulations, and internal policies affecting UM and prior authorization.
Monitor resource utilization, risk management, and quality of care; assist with reporting, record maintenance, and ensuring compliance with professional standards, CMS/NCD/LCD, payer requirements, and state/federal regulations.

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

Website LinkedIn See all jobs →

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:

Day (United States of America)

Scheduled Weekly Hours:

Union Position:

Department Details

Summary

Conduct level of care medical necessity reviews within patient’s medical records. Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements. Completes/coordinates activities relating to the implementation, ongoing evaluation, and improvements to UM and/or prior authorization processes with applicable. Completes activities relating to determination of medical necessity, authorization, continued stay review including diagnosis and procedural coding for working diagnosis related group (DRG) assignments.

Job Description

Workflows may include patient chart review, and assisting with and managing of insurance coverage and denials, prior authorizations, scheduled procedures, same-day readmission reviews, as well as length of stay. Ensure validation of appropriate level of care for pre-admission surgical reviews prior to admission. Reviews include InterQual clinical decision support criteria to ensure both the appropriateness of medical services and effective cost control. Ability to determine appropriate action for referring cases that do not meet departmental standards and require additional secondary review and/or escalation as needed. May also be actively involved in collaborating with members of the healthcare team to promote medically necessary resource utilization and achievement of fiscal outcomes when appropriate. Collaborates with physicians and other clinical professionals as needed to assist in documentation improvement practices for effective and appropriate services. Dynamic and tactful interpersonal skills, particularly in relating to physicians and other health care professionals. Educates members of the healthcare team regarding trends, external regulations and internal policies that effect resource utilization and potentially, prior authorization. Assists the department in monitoring the utilization of resources, risk management and quality of care for patients in accordance with guidelines and criteria. Assist in report preparation, correspondence, and maintenance of appropriate records. Ensure services comply with professional standards, national and local coverage determinations (NCD/LCD), centers for Medicare and Medicaid services (CMS), as well as state and federal regulatory requirements. Maintain working knowledge of payer standards for UM functions for authorization requirements. May assist with additional special projects related to work, upcoming initiatives, new organizational goals and audits when delegated. Considered a resource to all team members and acts as a point of contact for guidance, training, and assisting with questions. Demonstrate flexibility and adaptability where scheduling may fluctuate due to communication needs within interdepartmental and clinical units are required.

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).

Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing. 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.