Associate Appeal & Denial Specialist - Appeals and Denials

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

Responsible for the accurate coordination, efficient administration and resolution of appeals, denials and grievances for all product lines in a timely and efficient way.Appropriately handle and prioritize various daily tasks, with the ability to learn and apply Sanford Health Plan policies and regulatory requirements consistently, and the judgment to seek out guidance as needed. 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. May be required to perform medical necessity reviews, when needed, to make the determinations on policies. Must 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.

POSITION RESPONSIBILITIES

Strives to complete assignments according to established quality measures. Identifies the procedures for
making sure that results are mistake-free. Collects updated assessment and diagnosis information from industry
publications. Processes large quantities of detailed information with high levels of accuracy. Explains privacy, confidentiality,
and legal concerns with patient health information. Focuses activities on developing and maintaining positive customer
relationships. Describes technical standards and procedures that affect the customer support position. Describes the need
for setting priorities and establishing milestones as part of delegation. Uses key features and facilities of office software
available at the desktop. Writes documents that are correct in mechanics - spelling, grammar, punctuation, sentence
structure. Demonstrates the ability to complete work in a manner consistent with organizational values. Uses active listening skills and probing techniques to understand cause of a conflict.

DEPARTMENT DETAILS

The Associate Appeals and Denials Specialist reviews post service benefit denials and appeals for all lines of business at Sanford Health Plan. The Specialist also handles Member complaints, and must work collaboratively with other departments to resolve member concerns.
The Specialist may required to communicate with Members and Providers if needed to process appeals and complaints. Professional verbal and written communication skills are required. Ability to multi-task while meeting required regulatory timelines is also necessary.

QUALIFICATIONS

Pharmacy Technician Certification (CPhT) or currently holds an unencumbered LPN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multi-state licensure if in a Nurse Licensure Compact (NLC) state. Obtains and subsequently maintains required department specific competencies and certifications may be required. High school diploma or equivalence required. At least two years of customer service experience preferred.

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: req25351