Sanford Health Utilization Review Specialist in Fargo, North Dakota
Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.
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Facility: 45th St Business Center - PFS
Location: Fargo, ND
Address: 300 45th St S, Fargo, ND 58103, USA
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40.00
Provide quality assurance of medical care. Perform quality control related to patient treatment by medical staff to ensure clinical roles provided adequately for patients' comfort, health and safety. Identify quality issues through analysis of data and evaluation of clinical or business processes. Responsible for reviewing medical records and preparing clinical appeals, as appropriate, on medical necessity, level of care, length of stay, and authorization denials for hospitalized patients. Understand and provide insight into evaluating current process improvement strategies including quality, methods, and ability to maintain focus on the continuous improvement of processes, products and services. Provide feedback and education to other departments for denial prevention. Provide clinical insight into issues preventing insurance billing from occurring. Serve as an advocate for patients and families needing an explanation of their charges and/or price estimates prior to procedures. Work as a liaison with third party auditors in scheduling and conducting audits for the enterprise. Verify patient charges to medical record if needed. Maintain a working knowledge of accounts receivable as well as remain current regarding federal and state regulations governing the verification of charges. Must remain competent in nursing practices with in-depth understanding of an array of illnesses, intensity of service, and care coordination needs in order to integrate clinical knowledge with billing knowledge. Serve as the expert for Patient Financial Services for denials related to medical necessity of care. Cultivate positive working relationships with all internal and external contacts. Collaborate with multiple departments to improve process. Must understand and demonstrate leadership capability, handling conflict as it arises, and negotiate effectively. Serve as an expert resource and role model. Must be able to organize and prioritize tasks effectively.
Flexible hours. Work from home option once quality and productivity standards are met
Graduate from an accredited practical nursing program as an LPN required, RN preferred.
Five years' experience in a clinical setting required. Preference given to individuals with experience in utilization or with CPT/ICD knowledge.
Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, sick leave and paid time off. To review your benefit eligibility, visit https://sanfordhealth.jobs/benefits .
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 email@example.com .
Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment.
Job Function: Revenue Cycle
Req Number: R-40917