Current jobs related to Sanford Health | Referral Specialist, RN, Health Plan - sioux falls - Sanford Health


  • Sioux Falls, United States Sanford Health Full time

    Referral Specialist, RN, Health Plan at Sanford Health summary: The Referral Specialist, RN at Sanford Health is responsible for managing out-of-network exception requests and providing care coordination for health plan members. This role includes collaborating with providers, ensuring authorization processes are compliant with guidelines, and educating team...


  • Sioux Falls, United States Sanford Health Full time

    Careers With Purpose 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. Facility: GSS National Campus ...


  • Sioux Falls, United States Sanford Health Full time

    Careers With Purpose 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. Facility: GSS National Campus ...


  • Sioux Falls, United States Sanford Health Full time

    Careers With Purpose 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. Facility: GSS National Campus ...


  • Sioux Falls, United States Sanford Health Full time

    Careers With Purpose 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. Facility: GSS National Campus ...


  • Sioux Falls, United States Sanford Health Full time

    Job DescriptionCareers With PurposeSanford 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.Facility: GSS...


  • sioux falls, United States Sanford Health Full time

    Careers With Purpose At Sanford Health and the Good Samaritan Society, we have made a system-wide commitment to the integration and collaboration of behavioral health and primary care. Join one of the largest and fastest-growing not-for-profit health systems in the United States, where behavioral health is rooted in innovation and empowering people to...


  • Sioux Falls, United States Sanford Health Full time

    Careers With Purpose At Sanford Health and the Good Samaritan Society, we have made a system-wide commitment to the integration and collaboration of behavioral health and primary care. Join one of the largest and fastest-growing not-for-profit health systems in the United States, where behavioral health is rooted in innovation and empowering people to...


  • sioux falls, United States Sanford Health Full time

    Careers With Purpose At Sanford Health and the Good Samaritan Society, we have made a system-wide commitment to the integration and collaboration of behavioral health and primary care. Join one of the largest and fastest-growing not-for-profit health systems in the United States, where behavioral health is rooted in innovation and empowering people to...

  • Sanford Health | RN

    4 days ago


    sioux falls, United States Sanford Health Full time

    RN - Ophthalmology at Sanford Health summary:The Registered Nurse (RN) specializing in Ophthalmology at Sanford Health provides individualized nursing care, utilizing advanced technology and techniques to enhance patient recovery and vision. This full-time position allows for flexible scheduling and offers numerous opportunities for professional development...


  • sioux falls, United States Sanford Health Full time

    RN Peer Review Specialist - Sioux Falls or Fargo at Sanford Health summary: The RN Peer Review Specialist at Sanford Health facilitates peer review processes for healthcare providers, ensuring quality care in both inpatient and outpatient settings. This role involves gathering clinical data, preparing reports, and collaborating with medical staff to...

  • Sanford Health | RN

    5 days ago


    sioux falls, United States Sanford Health Full time

    Careers With Purpose 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. Facility: Talley Building ...

  • Sanford Health | RN

    5 days ago


    sioux falls, United States Sanford Health Full time

    RN - Cardiovascular Institute at Sanford Health summary: As a Registered Nurse at Sanford Health's Cardiovascular Institute, you will provide specialized nursing care to patients, utilizing the nursing process to ensure individualized care. This position involves collaboration with healthcare professionals to assess, plan, and evaluate patient treatments...

  • Sanford Health | RN

    5 days ago


    sioux falls, United States Sanford Health Full time

    RN - Center For Screening at Sanford Health summary: As a Registered Nurse (RN) at Sanford Health's Center for Screening, you will provide high-quality patient care in a fast-paced environment while collaborating with healthcare teams. This role includes planning patient care, conducting assessments, and offering education across various stages of...


  • sioux falls, United States Sanford Health Full time

    LPN - ENT at Sanford Health summary:As a Licensed Practical Nurse (LPN) in ENT at Sanford Health, you will provide holistic care to patients, ensuring their health, comfort, and safety throughout their healthcare journey. This role involves working under the supervision of healthcare professionals while documenting medical histories and administering...


  • Sioux Falls, United States Sanford Health Full time

    RN - Registered Nurse - Surgical Trauma - Full Time Nights/Weekends at Sanford Health summary: The Registered Nurse (RN) in the Surgical Trauma unit at Sanford Health provides individualized nursing care to surgical patients. This position involves the use of the nursing process to assess, plan, implement, and evaluate care, requiring strong critical...


  • Sioux Falls, United States Sanford Health Full time

    Registered Nurse - PICU - Full Time at Sanford Health summary: As a Registered Nurse in the Pediatric Intensive Care Unit (PICU) at Sanford Children‘s Castle of Care Hospital, you will provide exceptional care to critically ill pediatric patients. This role involves planning and coordinating patient care, collaborating with medical professionals, and...

  • Sanford Health | RN

    5 days ago


    sioux falls, United States Sanford Health Full time

    RN - Cardiac Device Clinic at Sanford Health summary: The RN - Cardiac Device Clinic at Sanford Health provides specialized nursing care focusing on patients with cardiac conditions. The role involves assessing patient needs, coordinating care, and collaborating with healthcare professionals while utilizing advanced technology. This full-time position...

  • Sanford Health | RN

    5 days ago


    sioux falls, United States Sanford Health Full time

    RN - Pediatric Hematology & Oncology - SCSC - FT at Sanford Health summary: The Registered Nurse (RN) in Pediatric Hematology & Oncology at Sanford Health provides individualized nursing care to children with hematological and oncological conditions. Key responsibilities include patient assessment, triage, administering chemotherapy, and collaborating...

  • Sanford Health | RN

    5 days ago


    Sioux Falls, SD, United States Sanford Health Full time

    Careers With Purpose 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. Facility: Talley...

Sanford Health | Referral Specialist, RN, Health Plan

2 weeks ago


sioux falls, United States Sanford Health Full time
Referral Specialist, RN, Health Plan at Sanford Health summary:

The Referral Specialist, RN at Sanford Health is responsible for coordinating care and managing out-of-network exception requests for Health Plan members. This role involves collaborating with healthcare providers, interpreting clinical information, and ensuring adherence to regulatory requirements within a managed care organization. The specialist must possess strong clinical knowledge, effective communication skills, and the ability to prioritize various tasks to facilitate optimal resource utilization and quality care.

Careers With Purpose

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.

Facility: GSS National Campus

Location: Sioux Falls, SD

Address: 4800 W 57th St, Sioux Falls, SD 57108, USA

Shift: Day

Job Schedule: Full time

Weekly Hours: 40.00

Salary Range: $27.50 - $44.00

Department Details

Monday through Friday, 8 am to 5 pm, No weekends or holidays, Opportunity to work from home

Job Summary

Communicate with providers and/or members regarding management of out-of-network exception requests. Provide care coordination for designated Health Plan members that includes managing and directing members to appropriate resources, services and programs. Work directly with referring providers and participating provider specialty groups in coordinating care.

Responsible for managing the authorization process for participating plan members ensuring that all services are performed within assigned evidence-based guidelines and performed at the appropriate level of care in a timely, cost-effective and efficient manner. The collection and interpretation of clinical information is necessary to initiate and execute authorizations. Essential functions must occur simultaneously; therefore, the specialist must be able to appropriately handle and prioritize various daily tasks. Must be able to collaborate with other health plan departments as needed for medical coverage, case agreement negotiation and policy application. Obtain and maintain appropriate documentation concerning services in accordance to regulatory and accreditation guidelines and timelines. Provide information to providers and members in regards to authorization and/or denial of services. Ability to review, analyze and summarize reports and have effective oral and written communication skills. Understanding of medical terminology, international classification of diseases and current procedural terminology (CPT) codes. Understanding and administration of medical, administrative and management principles and policy necessary to operate within a managed care organization.

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.

Possesses strong clinical knowledge and skills. Collaborates with team members both internally and externally to ensure care is coordinated and appropriate based on evidence based medicine. Ability to work independently or as a member of a team. Ability to multitask and work with little direction. Works primarily day hours.

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.

Assist with coordination of activities related to insurance pre-certification/authorization. Provide counseling to members or their representative regarding pre-service requirements and instructions.

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).

Will consider applicant with significant background in case management and/or utilization management experience. Minimum of three years nursing experience is 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.

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 401(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 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.

Req Number: R-

Job Function: Health Plan

Featured: No


Keywords:

Referral Specialist, Health Plan, Care Coordination, Registered Nurse, Authorization Management, Clinical Knowledge, Insurance Pre-certification, Regulatory Compliance, Healthcare Provider Collaboration, Utilization Management