Manager, Health Plan Utilization Management - RN

Careers With Purpose

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in Americas heartland.

Facility: GSS National Campus
Location: Sioux Falls, SD
Address: 4800 W 57th St, Sioux Falls, SD 57108, USA
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40.00

Department Details

Oversee health plan utilization management department operations including prior authorization, and concurrent review focusing on improving care quality and outcomes across a diverse member population while ensuring compliance with CMS, NCQA, and state/federal guidelines.

Job Summary

Responsible for the day to day oversight of department function both in terms of provision of service and providing direct supervision of all departmental staff. Maintains a standardization of utilization management process to ensure all policies and procedures are followed effectively and efficiently. Considered an expert resource with the centers for Medicare and Medicaid services (CMS). Coordinates authorization/certification of care for designated populations to establish medical necessity and ensure maximum reimbursement while maintaining a high level of customer satisfaction. Actively involved in reviewing information submitted by internal or external referral sources regarding a variety of cases which have the potential to develop into complex and/or costly scenarios and assisting the finance department in understanding the financial implications of these conditions. Additionally includes admission certification, continued stay authorization, clinical documentation improvement, and interaction with payers. Additional duties include management of medical denials, appeals, and grievances.

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. Manage processes to support attainment of goals within department and organization. Knowledgeable of industry standards, governing bodies, and regulations.

Adjusts to new or changing assignments, processes, and people. Being a positive role model for staff to coach, educate and support both the employees and organizational growth. Determines individual and team competency requirements, vulnerabilities, and learning needs. Assumes management responsibilities such as payroll, scheduling, day-to-day staffing and crucial conversations in collaboration with human resources and leadership. Identifies opportunity for personal and professional growth and pursues educational opportunities.

Qualifications

Bachelor's degree in nursing required. Master'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).

Four years of clinical nursing experience required. Two years experience as a case manager preferred. One year of leadership/management experience preferred. Experience in medical necessity review preferred.

Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state. Obtains and subsequently maintains required department specific competencies and certifications. Certification is encouraged and may be required depending on specialty or service area.

Benefits

Sanford 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 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-0255244
Job Function: Care Coordination
Featured: No