Job Summary

determines if insurance meets prior authorization criteria. Collects necessary documentation and communicates with third party payers, healthcare professionals and customers to prioritize requests.

Verifies patient registration and confirms benefit coverage, including deductibles and out-of-pocket expenses; researches and verifies covered benefits for ordered tests, procedures, and other services.

Responsible for assuring that prior authorization for medical services, including testing, procedures, surgery, Durable Medical Equipment (DME), and medications is completed and confirmed.

Obtains diagnosis(es) / CPT code(s) from medical chart and / or provider office. Contacts third party payer to determine appropriate prior authorization process.

Works closely with provider offices to obtain and clarify documentation to demonstrate medical necessity. If medical necessity criteria are not met, follows up with provider offices with guidance for Advanced Beneficiary Notices (ABN) or waivers that releases the financial burden of scheduled services from the facility to the patient.

Reviews professional services denials; works with clinics and third party payers on appeal process.

Assures all required referrals are in place; may work on outgoing referrals for care outside Sanford Health. May have minimal telephonic patient interaction concerning provider referrals.

May notify appropriate insurance companies when patients have checked in for inpatient services and procedures requiring observation periods.

Documents work in case management module; provides direction to utilization management, case management, and nursing regarding what action needs to be taken.

Collaborates with case management, social work, utilization management, and other cross-functional teams across the enterprise.

Assists with the design and management of data including the preparation of reports and presentations.

Qualifications

High school diploma or equivalent preferred; post-secondary education helpful.

Minimum of two years of experience in a hospital or clinic setting required. Understanding of medical terminology, insurance background, office equipment and computers is required.

Benefits

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 (k) retirement plan, work / life balance benefits, and a generous time off package to maintain a healthy home-work balance.

For more information about Total Rewards, visit .

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 or send an email to .

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.

Last updated : 2024-04-24