Sanford Health RN Utilization Management Specialist - Patient Access in Sioux Falls, South Dakota
Job Title: RN Utilization Management Specialist | Patient Access | Multi City
Department : PATIENT ACCESS MANAGEMENT
Job Schedule: Full Time
Hours Per Shift: 8 hr
#featuredjob Performs utilization management activities in accordance with Utilization Management Plan to assure compliance with accreditation/regulatory requirements. Completes/coordinates activities relating to the implementation, ongoing evaluation and improvements to utilization management processes and/or prior authorization processes. Completes activities relating to determination of medical necessity, authorization, continued stay review and outlier review including diagnosis and procedural coding for working diagnosis related group (DRG) assignment. Collaborates with members of the healthcare team to promote medically necessary resource utilization and achievement of fiscal outcomes. Assists in report preparation, correspondence and maintenance of appropriate records. Educates members of the healthcare team regarding trends, external regulations and internal policies that effect resource utilization and prior authorization. Organizational and communication skills. Dynamic and tactful interpersonal skills, particularly in relating to physicians and other health care professionals. Critical thinking and problem solving skills. Ability to organize complex systems of data. Ability to work effectively with both people and data including detailed information. Data management, retrieval and analysis skills. Knowledge of statistics and statistical data displays. Personal commitment to quality of care.
Manage and complete authorization within the work queues. Assist with and manage Insurance Denials. Review medical policies and review for medical necessity for scheduled procedures. Verify insurance coverage through established methods. The UMRN will be required to work primarily day hours, but may be required to work some evenings to ensure contact with case managed Members. Work is in an office environment and basically telephonic/computer. May occasionally have face to face contact with Members in the office setting. NOTE: This position is week day hours, and has the opportunity to work from home after orientation is complete.
Currently licensed with the applicable State Nursing Board and/or possess multistate licensure privileges as required by position. Bachelors degree in nursing from a NLN or AACN accredited nursing program required. NOTE: This position is week day hours, and has the opportunity to work from home after orientation is complete.
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 1-877-243-1372 or send an email to email@example.com .
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 .
Job Function: Nursing
Job Schedule: Full Time
Req Number: req12273