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Utilization Management Coordinator - Center for Care Management - FT Days

Company: Sanford Health
Location: Sioux Falls
Posted on: June 10, 2021

Job Description:

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.

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Facility: Central Patient Building

Location: Sioux Falls, SD

Address: 1305 W 18th St, Sioux Falls, SD 57105, USA

Shift: 8 Hours - Day Shifts

Job Schedule: Full time

Weekly Hours: 40.00

Department Details

  • Clinical role - reviewing charts and communicating with insurance companies.
  • Working 8 hour shifts mostly between hours of 7:00am-6:00pm.

Job Summary

Monitors the utilization of resources, risk management and quality of care for patients in accordance to established guidelines and criteria for designated setting and status. Collection of clinical information necessary to initiate commercial payor authorization. Obtain and maintain appropriate documentation concerning services in accordance to reimbursement agency guidelines. Consult with interdepartmental departments and staff to assure all relevant information regarding patient status and diagnosis are accurately reported. Provide information via multiple sources of technology applications to insurance companies and contracted vendors to assure authorization for patients. May participate in providing assistance in financial aid and/or counseling if applicable.

Accurately recognizes coding principle diagnosis and principle procedures including complicating/comorbid diagnoses for accurate diagnosis-related group (DRG) assignment during hospitalization. Monitors patient hospitalization to ensure prospective payment limit is not exceeded without due notice to the attending physician. May also need to notify physician and patient of authorization denials. Inputs collected data into computer system for insurance communication, DRG grouping, data abstraction for monitoring and evaluation, and when applicable, Medicare National and Local Coverage Determinations (NCD/LCD), and Joint Commission (TJC) required functions and credentialing. Assists medical records coding personnel as needed to correctly identify diagnoses and procedures, and obtains physician documentation as needed. Monitors patient hospitalization to ascertain medical necessity and appropriateness. Assists with retrospective review of specified charts as required.

Ability to interact on an interpersonal basis with both providers and nursing staff. Demonstrates proficiency with computers, Microsoft applications, and additional designated technology within the department. Will perform multiple administrative duties including accurate record keeping and electronic data management when needed. Ability to work with growth and development needs of pediatric to geriatric populations.


Appropriate education level required in accordance with licensure.

Seven years of relevant experience, superior communication and interpersonal skills. Minimum one year healthcare or clinical experience required.

Specific background or experience in healthcare reimbursement, insurance industry, and/or authorization experience would be critical to the success in this role and preferred.

Currently holds an unencumbered Licensed Practical Nurse (LPN) license with State Nursing board and/or possess multi-state licensure privileges, or Registered Health Information Technician (RHIT) required. Additionally, coding certifications also acceptable, i.e. Certified Coding Specialist (CCS), Certified Coding Specialist - Physician based (CCS-P), Certified Professional Coder (CPC), Certified Professional Coder - Hospital (CPC-H), Certified Outpatient Coder (COC), or Certified Ambulance Coder (CAC).

Obtains and subsequently maintains required department specific competencies and certifications.


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, sick leave and paid time off. To review your benefit eligibility, 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 1-877-673-0854 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.

Job Function: Care Coordination

Req Number: R-48171

Featured: No

Keywords: Sanford Health, Sioux Falls , Utilization Management Coordinator - Center for Care Management - FT Days, Other , Sioux Falls, South Dakota

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