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.