Lead Utilization Management Specialist - Appeals

Sanford Health•Time, IL

2d•$29 - $47•Remote

About The Position

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: 40 Salary Range: $29.00 - $46.50 Union Position: No 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.

Requirements

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.
Obtains and subsequently maintains required department specific competencies and certifications.

Nice To Haves

Certified Professional in Healthcare Quality 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.
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.