Senior Appeal and Denial Specialist

Summary

Facilitates the denial and appeal process through exercising clinical expertise by reviewing medical records for medical necessity and policy requirements. Responsible for leveraging clinical knowledge and standard procedures to track appeals through first, second, and subsequent levels, and ensuring timely filing of appeals as required by contracts and regulations, in addition to promoting departmental awareness of clinical best practices.

Job Description

• Administer and prioritize daily tasks, and apply Sanford Health Plan policies and regulatory requirements consistently and use good judgment as when to seek out guidance.
• Possess broad understanding of products and benefits and a demonstrated understanding of regulatory requirements and timeframes.
• Acquire a deep knowledge of product network requirements and make case decisions accordingly.
• Contributes to the establishment of best practices for audit and compliance.
• Ensures compliance with current government and industry audit practices and requirements.
• Conduct review of clinical-based denials (i.e. Medical Necessity, Level of Care) within required timeframes utilizing clinical criteria sets, knowledge of payor regulations, and considerable clinical judgment, to determine appropriateness of care.
• Coaches patients and families on how to be proactive in managing their own care.
• Consults on the process for identifying and resolving common barriers to patient progress.
• Establishes shared goals to foster collaboration.
• Delivers written and oral communication, responds to questions and concerns, and produces specific outcomes and impact.
• Demonstrates in-depth knowledge of organization's policies and practices requiring confidentiality.
• Implements tactics to de-escalate problem situations immediately.
• Delegates appropriate levels of responsibility and authority.
• Communicates well downward, upward, and outward.
• Anticipates changing business situations, adjusts priorities accordingly and gathers necessary resources to achieve the goal.
• Exchanges private healthcare information with other facilities, such as insurance companies and pharmacies, according to regulations.
• Demonstrates experience working with multiple healthcare organizations or providers.
• Applies policies and procedures designed to ensure compliance with policies and ethical codes.
• Collaborates and communicates with all departments of a healthcare organization for the preparation for external audits.
• Mentors others in their technical areas and shares expertise on critical issues.
• Responds to shifting priorities while maintaining progress of regularly scheduled work.
• Implements effective medical case management strategies.
• Adapts language, tone, structure, and level of detail to the needs of others.
• Uses varying problem-solving approaches and techniques as appropriate.
• Streamlines the critical workflow for executing key processes.
• Promotes understanding of multiple product and service groups and their interdependencies.

Qualifications

• Bachelor's degree required, or a combination of applicable degree completion and applicable experience will be considered.
• Graduate from a nationally accredited nursing program preferred, 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).
• Three (3) years' experience required in appeals, medical necessity, or prior authorization process.
• If a graduate of a nursing program, currently licensed with the applicable State Nursing Board and/or possess multistate licensure privileges as required by position.