Registered Nurse Appeal Specialist

Job Summary

To support the appeal and denial process, the full-time Senior Appeal and Denial Specialist will leverage clinical expertise to review medical records, manage appeals through various levels, and ensure compliance with regulatory requirements in a fully remote setting.

Key responsibilities

• Facilitate the denial and appeal process by reviewing clinical-based denials and applying clinical criteria sets
• Administer daily tasks while ensuring adherence to Sanford Health Plan policies and regulatory requirements
• Collaborate with healthcare departments to prepare for external audits and establish best practices for compliance

Required qualifications

• Bachelor's degree required; a combination of education and experience may be considered
• Graduate from a nationally accredited nursing program preferred
• Three years of experience in appeals, medical necessity, or prior authorization processes
• Current nursing license with the applicable State Nursing Board or multistate licensure privileges as required