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Appeals and Denials Specialist - LPN

Sanford Health

Posted/Updated: 19 days ago

Job Description

Responsible for the accurate coordination, efficient administration and resolution of appeals, denials and grievances for all product lines in a timely and efficient way.

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.

Coordinate and determine appeals and denials, and then make determinations based on member policy documents, and/or medical or pharmacy criteria guidelines. Communicate determinations with members, providers and third parties regarding status.

Triage appeals and denials to meet the needs of urgent requests, both over the phone through the mail. Routinely communicate and collaborate with internal and external constituents about highly escalated issues.

May be required to perform medical necessity reviews, when needed, to make the determinations on policies.

Demonstrate strong communications skills, both on the phone and in writing, with a strong understanding of medical terminology and a high level of attention to detail.

Job Requirements
Four years of work experience required.

Requires an unencumbered Licensed Practical Nurse (LPN) license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state. Obtains and subsequently maintains required department specific competencies and certifications may be required.
Sanford Health


The investment Sanford Health makes in its relationship with employees goes well beyond just a paycheck. We are dedicated to providing a comprehensive, flexible benefits package for you and your family that meets not only today’s needs but also those in the future. Health Insurance - Single and family coverage - Multiple deductible options - Low office visit and pharmacy co-pays Beyond the Basics - Dental insurance - Vision insurance - Flexible spending accounts - Paid time off - 401(k) retirement savings Additional Benefits Eligible employees receive the following benefits at no cost: - Basic life insurance - Short-term disability - Long-term disability Eligible employees are also offered: - Voluntary life insurance - Accident insurance - Cancer insurance - Critical illness insurance - Universal life insurance - Legal services - Identity theft protection - Sanford Health Plan offers wellness coaching services to help you meet your health and wellness goals. Plans may vary by location and employment status