Sanford Health Utilization Management Specialist - Utilization Management in Sioux Falls, South Dakota
Job Title: Utilization Management Specialist | Utilization Management | Sioux Falls
City: Sioux Falls
Department : Utilization Management - Sioux Falls
Job Schedule: Full Time
Hours Per Shift: 8 hr
Conduct level of care medical necessity reviews within patients medical records. Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements. Completes/coordinates activities relating to the implementation, ongoing evaluation, and improvements to UM and/or prior authorization processes with applicable. Completes activities relating to determination of medical necessity, authorization, continued stay review including diagnosis and procedural coding for working diagnosis related group (DRG) assignments. Workflows may include patient chart review, and assisting with and managing of insurance coverage and denials, prior authorizations, scheduled procedures, same-day readmission reviews, as well as length of stay. Ensure validation of appropriate level of care for pre-admission surgical reviews prior to admission. Reviews include InterQual clinical decision support criteria to ensure both the appropriateness of medical services and effective cost control. Ability to determine appropriate action for referring cases that do not meet departmental standards and require additional secondary review and/or escalation as needed. May also be actively involved in collaborating with members of the healthcare team to promote medically necessary resource utilization and achievement of fiscal outcomes when appropriate. Collaborates with physicians and other clinical professionals as needed to assist in documentation improvement practices for effective and appropriate services. Dynamic and tactful interpersonal skills, particularly in relating to physicians and other health care professionals. Educates members of the healthcare team regarding trends, external regulations and internal policies that effect resource utilization and potentially, prior authorization. Assists the department in monitoring the utilization of resources, risk management and quality of care for patients in accordance with guidelines and criteria. Assist in report preparation, correspondence, and maintenance of appropriate records. Ensure services comply with professional standards, national and local coverage determinations (NCD/LCD), centers for Medicare and Medicaid services (CMS), as well as state and federal regulatory requirements. Maintain working knowledge of payer standards for UM functions for authorization requirements. May assist with additional special projects related to work, upcoming initiatives, new organizational goals and audits when delegated. Considered a resource to all team members and acts as a point of contact for guidance, training, and assisting with questions. Demonstrate flexibility and adaptability where scheduling may fluctuate due to communication needs within interdepartmental and clinical units are required.
Adjusts to new or changing assignments, processes, and people.;Verifies if collected data is appropriate for reimbursement, utilizing related legal guidelines.;Utilizes specific approaches and tools for checking and cross-checking outputs.;Organizes and prioritizes the sequence of steps to be taken to remedy the situation.;Maintains sense of commitment to success, personal achievement and satisfaction.;Identifies potential changes that reduce costs without impacting the quality of patient care.;Helps promote collaboration across generations, functions, regions, and levels.;Follows-up with customers to answer questions and ensure satisfaction.;Demonstrates experience engendering collaborative processes that lead to problem solving and the achievement of business goals.;Delivers written and oral communication, responds to questions and concerns, and produce specific outcomes and impact.;Assists patients in accessing specialized providers through the use of referrals or pre-approvals.;Assists in assessing risks, benefits and consideration of alternatives.;Applies available tools and resources to work efficiently.;
Bachelor's degree in nursing preferred. Graduate from a nationally accredited nursing program required, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing. Obtains and subsequently maintains required department specific competencies and certifications.
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 firstname.lastname@example.org .
City: Sioux Falls
Job Function: Health Plan
Job Schedule: Full Time
Req Number: WD02435