Key Facts

Remote From:

Full time

English

Hard Skills

Electronic Referrals CPT Coding Prior Authorization Medical Device Directive Data Management Communicating With Patients Case Management Systems Presentation Design Medical Necessity Medical Abbreviations Clinical Data Analysis Prior Authorization Appeals Utilization Management Patient Registration Office Equipment Manuscript Collections Cross-Functional Collaboration Telephony

Other Skills

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Computer Literacy
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Report Writing
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Communication
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Time Management
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Customer Service
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Detail Oriented

Roles & Responsibilities

High school diploma or equivalent (preferred; post-secondary education helpful)
Minimum of two years of experience in a hospital or clinic setting
Understanding of medical terminology and insurance background
Proficiency with office equipment and computers

Requirements:

Review and validate insurance eligibility and obtain prior authorization for medical services, tests, procedures, DME, and medications; obtain diagnoses and CPT codes and coordinate with third-party payers
Verify patient registration and benefit coverage (deductibles and out-of-pocket costs); collect necessary documentation and communicate with providers, payers, and patients
Manage referrals and authorization; ensure referrals are in place; address ABN/waivers when medical necessity is not met and assist with denials/appeals
Document activities in the case management system and collaborate with utilization management, case management, nursing, social work, and other teams; assist with data reporting and presentations

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: $16.50 - $26.50

Union Position:

Department Details

Summary

The Patient Access Specialist reviews and validates insurance eligibility, prior authorization and/or referral of medication, procedures, etc.; determines if insurance meets prior authorization criteria.

Job Description

Collects necessary documentation and communicates with third party payers, healthcare professionals and customers to prioritize requests. Verifies patient registration and confirms benefit coverage, including deductibles and out-of-pocket expenses; researches and verifies covered benefits for ordered tests, procedures, and other services. Responsible for assuring that prior authorization for medical services, including testing, procedures, surgery, Durable Medical Equipment (DME), and medications is completed and confirmed. Obtains diagnosis(es)/CPT code(s) from medical chart and/or provider office. Contacts third party payer to determine appropriate prior authorization process. Works closely with provider offices to obtain and clarify documentation to demonstrate medical necessity. If medical necessity criteria are not met, follows up with provider offices with guidance for Advanced Beneficiary Notices (ABN) or waivers that releases the financial burden of scheduled services from the facility to the patient. Reviews professional services denials; works with clinics and third party payers on appeal process. Assures all required referrals are in place; may work on outgoing referrals for care outside Sanford Health. May have minimal telephonic patient interaction concerning provider referrals. May notify appropriate insurance companies when patients have checked in for inpatient services and procedures requiring observation periods. Documents work in case management module; provides direction to utilization management, case management, and nursing regarding what action needs to be taken. Collaborates with case management, social work, utilization management, and other cross-functional teams across the enterprise. Assists with the design and management of data including the preparation of reports and presentations.

Qualifications

High school diploma or equivalent preferred; post-secondary education helpful.

Minimum of two years of experience in a hospital or clinic setting required. Understanding of medical terminology, insurance background, office equipment and computers is required.

**Open to internals applicants; open to external Wisconsin and Michigan residents**

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.