Referral Specialist Registered Nurse - Health Plan
Company: Sanford Health
Location: Sioux Falls
Posted on: February 2, 2025
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Job Description:
Referral Specialist Registered Nurse - Health Plan at Sanford
Health summary:
The Referral Specialist Registered Nurse plays a critical role in
coordinating care for health plan members, managing authorization
processes, and ensuring compliance with regulatory guidelines. This
position requires effective communication with healthcare providers
and members, along with a strong understanding of medical
terminology and coding. The specialist is responsible for
facilitating resource utilization and quality of care while
collaborating with other healthcare professionals.
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
https://sanfordcareers.com/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
talent@sanfordhealth.org . 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-0211077 Job Function: Health Plan Featured: No
Keywords:
Referral Specialist, Registered Nurse, Health Plan, Care
Coordination, Authorization Management, Healthcare Compliance,
Clinical Knowledge, Utilization Management, Patient
Advocacy
Keywords: Sanford Health, Sioux Falls , Referral Specialist Registered Nurse - Health Plan, Healthcare , Sioux Falls, South Dakota
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