Sanford Health Utilization Review Specialist - PFS Operations - Utilization Management in Sioux Falls, South Dakota

Job Title: Utilization Review Specialist | PFS Operations - Utilization Management | Sioux Falls

City: Sioux Falls

State: SD

Department : PFS Operations - Utilization Management

Job Schedule: Full Time

Shift: Varies

Hours Per Shift: 8 hr


Provide quality assurance of medical care. Perform quality control related to patient treatment by medical staff to ensure clinical roles provided adequately for patients' comfort, health and safety. Identify quality issues through analysis of data and evaluation of clinical or business processes. Responsible for reviewing medical records and preparing clinical appeals, as appropriate, on medical necessity, level of care, length of stay, and authorization denials for hospitalized patients. Understand and provide insight into evaluating current process improvement strategies including quality, methods, and ability to maintain focus on the continuous improvement of processes, products and services. Provide feedback and education to other departments for denial prevention. Provide clinical insight into issues preventing insurance billing from occurring. Serve as an advocate for patients and families needing an explanation of their charges and/or price estimates prior to procedures. Work as a liaison with third party auditors in scheduling and conducting audits for the enterprise. Verify patient charges to medical record if needed. Maintain a working knowledge of accounts receivable as well as remain current regarding federal and state regulations governing the verification of charges. Must remain competent in nursing practices with in-depth understanding of an array of illnesses, intensity of service, and care coordination needs in order to integrate clinical knowledge with billing knowledge. Serve as the expert for Patient Financial Services for denials related to medical necessity of care. Cultivate positive working relationships with all internal and external contacts. Collaborate with multiple departments to improve process. Must understand and demonstrate leadership capability, handling conflict as it arises, and negotiate effectively. Serve as an expert resource and role model. Must be able to organize and prioritize tasks effectively.


Gathers data to be used in the evaluation of treatments or technologies. Develops and presents reports on audit findings and recommendations. Conducts and directs quality reviews. Leads efforts to enhance organizational process capability. Conducts trend and root cause analysis to identify and address recurring problems. Review and analyze facility activities and data to aid planning and cash and risk management and to improve service utilization. Evaluate nursing intervention outcomes, conferring with other healthcare team members as necessary. Reviews and assesses information collected on a medical case. Evaluates the quality of managed care services via advanced tools and techniques. Evaluates treatments or procedures for effectiveness using an evidence-based approach.


The hours of this position are flexible between 0500-1900, Monday through Friday.


Graduate from an accredited practical nursing program as an LPN required, RN preferred. Five years' experience in a clinical setting required. Preference given to individuals with experience in utilization or with CPT/ICD knowledge. LPN 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: Revenue Cycle

Job Schedule: Full Time

Shift: Varies

Req Number: WD03108