Sanford Health Associate Appeal & Denial Specialist - Appeals and Denials in Sioux Falls, South Dakota

Job Title: Associate Appeal & Denial Specialist | Appeals and Denials | Sioux Falls

City: Sioux Falls

State: South Dakota

Department : Appeals and Denials

Job Schedule: Full Time

Shift: Days

Hours Per Shift: 8 hr

JOB SUMMARY

The Appeals and Denial Specialist performs the daily functions of appeal and denial resolution while applying clinical knowledge and evaluating medical necessity for all requests in a timely and efficient manner.

POSITION RESPONSIBILITIES

Review clinical information for all appeals utilizing clinical knowledge and Plan medical criteria to determine medical necessity of Member and Provider Appeals. Gather, analyze and communicate verbal and written information regarding member and provider clinical appeals, including information for follow up. Prepare response letters for member and provider clinical appeals. Maintain files and logs for all appeals Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale.

DEPARTMENT DETAILS

Performs medical necessity reviews for Internal Member and Provider Appeals for Sanford Health Plan. Candidate must be able to multitask, adhere to regulatory timelines and possess excellent Customer Service skills. LPN licensure required.

QUALIFICATIONS

Active LPN/LVN licensure. 2 years of clinical experience 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 talent@sanfordhealth.org .

In compliance with federal law requiring employers to verify new employees' U.S.

employment eligibility, Sanford participates in E-Verify. To learn more click here for English Version at https://e-verify.uscis.gov/emp/media/resourcesContents/EverifyPosterEnglish.pdf or here for Spanish Version at https://e-verify.uscis.gov/emp/media/resourcesContents/EverifyPosterSpanish.pdf .

City: Sioux Falls

State: South Dakota

Job Function: Health Plan

Job Schedule: Full Time

Shift: Days

Req Number: req24240