Appeal and Denial Specialist - Health Plan Claims

Sanford Health

1d • Onsite

About The Position

Responsible for accurate coordination of documentation, interpretation of policies, and handling of correspondence related to denials and appeals submitted by providers and members. Must administer benefits in accordance within appropriate regulatory timelines dependent on each product line. 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.

Requirements

• Bachelor's degree required, or a combination of applicable degree completion and applicable experience will be considered.
• One (1) year experience required in appeals, medical necessity, or prior authorization process.
• If a graduate of a nursing program, currently licensed with the applicable State Nursing Board and/or possess multistate licensure privileges as required by position.

Nice To Haves

• Graduate from a nationally accredited nursing program preferred, 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).

Responsibilities

• Administer and prioritize daily tasks, and apply Sanford Health Plan policies and regulatory requirements consistently and use good judgment as when to seek out guidance.
• Possess broad understanding of products and benefits and a demonstrated understanding of regulatory requirements and timeframes.
• Intake and coordinate appeals and denials, and then make determinations based on member policy documents, and/or medical criteria guidelines.
• Communicate determinations with members, providers and third parties regarding status.
• Conduct review of denials within required timeframes utilizing policy criteria sets, knowledge of payor regulations, and considerable judgment, to determine appropriateness of care.
• Triage appeals and denials to meet the needs of urgent requests, both over the phone through the mail.
• Routinely communicate and collaborate with internal and external constituents about highly escalated issues.
• May be required to perform medical necessity reviews, when needed, to make the determinations on policies.
• Demonstrate strong communications skills, both on the phone and in writing, with a strong understanding of medical terminology and a high level of attention to detail.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level