RN Utilization & Care Coordination Specialist

sanford; Sioux Falls (SD); On-site; USD 81,664,000 - 110,318,000; Full time

Job summary

Sanford Health in Sioux Falls, SD, seeks a registered nurse to conduct level-of-care medical necessity reviews within patient records and perform utilization management activities to ensure accreditation compliance.

Responsibilities include chart reviews, prior authorizations, and DRG-related coding, with collaboration across the care team to optimize patient outcomes and resource use. Training is provided on-site with future remote-work considerations.

Qualifications

• Bachelor's degree in nursing preferred.
• Graduate from a nationally accredited nursing program.
• Currently holds an unencumbered RN license with state board.

Responsibilities

• Perform level-of-care medical necessity reviews within patient records.
• Assist with and manage insurance coverage, denials, and prior authorizations.
• Coordinate UM activities and DRG coding for medical necessity and resource use.
• Collaborate with physicians and clinical staff to improve documentation and outcomes.
• Ensure compliance with CMS, NCD/LCD, and state/federal regulations; participate in audits.

Skills

Interpersonal skills

RN license

Education

Bachelor's degree in nursing

RN license

Job description

Sanford Health in Sioux Falls, SD, seeks a registered nurse to conduct level-of-care medical necessity reviews within patient records and perform utilization management activities to ensure accreditation compliance.

Responsibilities include chart reviews, prior authorizations, and DRG-related coding, with collaboration across the care team to optimize patient outcomes and resource use. Training is provided on-site with future remote-work considerations.