[Hiring] Appeal and Denial Specialist - Health Plan Claims @Sanford Health

Role Description

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.

• Administer and prioritize daily tasks, applying Sanford Health Plan policies and regulatory requirements consistently.
• Possess broad understanding of products and benefits and a demonstrated understanding of regulatory requirements and timeframes.
• Intake and coordinate appeals and denials, making 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.
• Triage appeals and denials to meet the needs of urgent requests, both over the phone and through the mail.
• Routinely communicate and collaborate with internal and external constituents about highly escalated issues.
• May be required to perform medical necessity reviews to make determinations on policies.
• Demonstrate strong communication skills, both on the phone and in writing, with a strong understanding of medical terminology and a high level of attention to detail.

Qualifications

• Bachelor's degree required, or a combination of applicable degree completion and applicable experience will be considered.
• Graduate from a nationally accredited nursing program preferred, including, but not limited to, CCNE, ACEN, and NLN CNEA.
• 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.

Company Description

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.