Lead Appeal and Denial Specialist

Sanford Health

5d•$24 - $39•Hybrid

About The Position

Responsible for performing advanced level work related to appeals and denials by conducting a comprehensive review of clinical documentation, writing compelling arguments based on the clinical documentation, and interpreting medical policies. The As a lead position, lead appeals and denial specialist this role will additional support the leads the team by providing management support, when the manager is unavailable and works to developing process improvement initiatives and, and leading problem solving resolution efforts with other team members.

Requirements

Bachelor's degree required, or a combination of applicable degree completion and applicable experience will be considered.
Five (5) year's 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).
Experience with with regulatory programs and data reporting preferred.

Responsibilities

Maintains a high level of subject matter expertise and possesses the ability to identify resources and support processes for the appeal and denial team.
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.
Leads team meetings.
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.
Coaches patients and families on how to be proactive in managing their own care.
Consults on the process for identifying and resolving common barriers to patent progress.
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.