Utilization Management Specialist (Home-Based) - Prior Authorization

10000 Sanford; United States; Remote; USD 58,000 - 80,000; Full time

Job summary

Sanford Health, the largest rural health system in the United States, seeks a registered nurse to perform utilization management, medical necessity reviews, and prior authorization coordination. The role supports compliant, cost-conscious care across our large network.

The RN will collaborate with physicians and care teams to ensure accurate documentation and appropriate resource utilization, including DRG assignments and outcome-focused reviews.

Qualifications

• Bachelor's degree in nursing preferred.
• Graduate from a nationally accredited nursing program (CCNE/ACEN/NLN CNEA).
• Currently holds an unencumbered RN license.

Responsibilities

• Conduct level of care medical necessity reviews in patient medical records.
• Perform utilization management activities to ensure accreditation/regulatory compliance.
• Coordinate activities related to UM and prior authorization processes and DRG assignments.
• Review pre-admission surgical cases and authorize appropriate levels of care.
• Collaborate with physicians and care teams to support documentation improvement and resource utilization.

Skills

RN license

Education

Bachelor's degree in nursing

Accredited nursing program (CCNE/ACEN/NLN CNEA)

Job description

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland.

Work Shift: Day (United States of America) Scheduled Weekly Hours: 40 Compensation: Salary Range: $27.50 - $38.50 Union Position: No Opportunity to work remote. RN license required.

Summary Conduct level of care medical necessity reviews within patient’s 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.

Job Description

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.

Qualifications

• 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.

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 1-877-949-5678 or send an email to [e-mail].

The Sanford organization owns and manages multiple distinct brands, including Sanford Health, Marshfield Clinic, and Good Samaritan, as well as Lewis Drug, Sanford Health Equip, Solutions by Sanford, Great Shots, and Blue Rock Bar & Grill. Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. Headquartered in Sioux Falls, South Dakota, the organization has 53,000 employees and serves over 2 million patients and nearly 425,000 health plan members across the upper Midwest including South Dakota, North Dakota, Minnesota, Wyoming, Iowa, Wisconsin and the Upper Peninsula of Michigan. The integrated nonprofit health system includes a network of 56 hospitals, 288 clinic locations, 147 senior care communities, 4,000 physicians and advanced practice providers and nearly 1,500 active clinical trials and studies. The organization’s transformational virtual care initiative brings patients closer to care with access to 78 specialties. Learn more about Sanford Health’s commitment to shaping the future of rural health care across the lifespan at sanfordhealth.org or Sanford Health News.

Good Samaritan, one of the nation’s largest nonprofit providers of senior care and services, is committed to transforming the aging experience through innovation, compassion and personalized care. As part of Sanford Health, an integrated nonprofit health system headquartered in Sioux Falls, South Dakota, Good Samaritan serves 10,000 seniors and offers access to a full continuum of care, including 94 rehabilitation and skilled nursing centers, 56 assisted living and memory care facilities, 44 independent living locations and 37 home health and hospice agencies. The senior care provider delivers services across the upper Midwest, with 70% of residents living in rural communities. Learn more about Good Samaritan’s mission and commitment to delivering high quality senior care in rural America at good-sam.com.