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Sanford Health Appeals and Denials Specialist - Health Plan - Member Experience in Sioux Falls, South Dakota

Job Title: Appeals and Denials Specialist | Health Plan - Member Experience | Sioux Falls

City: Sioux Falls

State: SD

Department : Health Plan - Member Experience - Sioux Falls

Job Schedule: Full Time

Shift: Days

Hours Per Shift: 8 hr


Responsible for the accurate coordination, efficient administration and resolution of appeals, denials and grievances for all product lines in a timely and efficient way.

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.

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.


Maintains a sense of urgency and a positive attitude.;Adheres to organizational quality management processes and practices.;Examines a specific problem and understands the perspective of each involved stakeholder.;Interprets documentation on the policies and standards regarding contact with the customer.;Analyzes problem trends and takes steps to avoid recurrence.;Ensures identification of customer needs and priorities.;Uses basic support tools for managing customer interactions.;Obtains information and addresses questions that can facilitate movement from problem to resolution stage.;Under guidance, deals with situations or information requiring confidentiality.;Analyzes policy and standards documentation and ensures organizational compliance.;Monitors all releases of patient information for compliance with HIPAA and other privacy laws.;


Bachelor's degree required.

Four years of work experience required.

May require Pharmacy Technician Certification (CPhT) or currently holds an unencumbered Licensed Practical Nurse (LPN) license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state. Obtains and subsequently maintains required department specific competencies and certifications may be required.

About Sanford Health:

At Sanford Health, we are dedicated to the work of health and healing.

Every day, we show that commitment by delivering the highest quality of care to the communities we serve.

We are leaders in health care and strive to provide patients across the region with convenient access to expert medical care, leading-edge technologies and world-class facilities.

In addition to strong clinical care, we are also committed to research, education and community growth.

We engage in medical research to not only discover innovative ways to provide care, but also cures for common diseases.

We continuously seek new ways to achieve our vision of improving the human condition here in your community, across the region and around the world.

The entire team at Sanford Health recognizes the value of healthy families and communities.

We continue to gain momentum and expand our reach. Together, we can make a positive difference now, and in the future.

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 .

City: Sioux Falls

State: SD

Job Function: Health Plan

Job Schedule: Full Time

Shift: Days

Req Number: WD08485