Supervisor, Utilization Management - Prior Authorization

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. 

Work Shift:

Day (United States of America)

Scheduled Weekly Hours:

40

Salary Range: $32.50 - $49.50

Union Position:

No

Department Details

Opportunity to work remote.

Summary

Direct supervisor for utilization management (UM) staff members within the financial clearance center. Provide direction on day-to-day activities as these groups interact with inpatient case management and utilization review teams.

Job Description

Meet with leadership in each market to build rapport and establish the collaborative link between the clinical roles within the financial clearance center and the needs related to medical necessity review within departments as it relates to prior authorization. Become the point person for regional leaders when questions arise regarding medical necessity. Keep abreast of changing insurance payor guidelines and updates. Demonstrate leadership to employees, serving as a role model, and encouraging vision and change projects. Understand the critical components associated and required to achieve intended results and ability to assist in hiring, selection, retaining, and leveraging talent across the unit. Collaborate and provides feedback in measuring employee performance. Assists in the training of new staff members and the development of existing staff members. Practices positive collaboration and converts difficult interactions into productive ones. Knowledge of quality management methods, tools, and techniques and ability to create and support an environment that meets the quality goals of the organization. Expected to assist in data monitoring, reports and improvements. Will serve and/or chair departmental/organization committees and task forces as needed. May be asked to assist with other projects or work assignments as needed by organization, department or leadership. Travel will be expected throughout all markets.

Qualifications

Associate's Degree in nursing is required. 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).

Experience within billing, coding, or insurance is necessary. Working with insurance companies, completing prior authorizations and familiarity with referral management is necessary. Working with online portals such as Evicore, Healthhelp, Evity, Availity, Humana, etc., is helpful. An understanding of medical necessity requirements and Center for Medicare and Medicaid Services (CMS) Guidelines desired. Experience working claim denials is also helpful. Working within the EPIC software system is also helpful but not required.

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 1-877-673-0854 or send an email to talent@sanfordhealth.org.