Sanford Health Payment Integrity Representative - PFS Revenue in Sioux Falls, South Dakota

Job Title: Payment Integrity Representative | PFS Revenue | Sioux Falls

City: Sioux Falls

State: SD

Department : PFS Revenue - Sioux Falls

Job Schedule: Full Time

Shift: Days

Hours Per Shift: 8 hr


Responsible for managing, maintaining and understanding all managed care contracts for system billing, maximizing reimbursement and maintaining compliant practices. Develop, document and oversee standard operating procedures to ensure consistency in business rules applied in claim adjudication. Possess in-depth understanding of the reimbursement techniques and strategies ensuring payments received as contracted. Maintain comprehensive knowledge of state and federal regulations that impact operations in order to respond properly. Responsible for the appeals related to underpayments & overpayments according to contract guidelines. Work with reimbursement analysis and testing by payor, analyze trending of managed care issues by payor, and assist in reviewing managed care activity in the system. Evaluate managed care contract performance, auditing payments under managed care contracts and government payment programs. Use department standards to sample payments and identify overpayments. Able to interpret complex reimbursement contracts and schedules in order to audit and review post-payment audits accurately. Review claims to verify all network discounts are applied as required. Assist in verification of overpayments for Medicare/government payors, reviewing for compliance. Support billing and finance in developing and conducting analysis and reporting to aid operational decision making. Produce, publish and distribute various reports and presentations for the department. Educate operational departments on charge capture processes in order to problem-solve managed care issues and provide leadership to drive them to resolution Serve as a resource for billing employees on payment problems they are unable to resolve. Facilitate education and distribution of relevant information to staff. Serve as a liaison between departments on billing and charging issues. Assist with identifying sources of problems and work to correct, recommending solutions as needed. Committed to working in a fast-paced and changing environment and have a high energy level and the ability to accomplish objectives. Cultivate positive working relationships with management, staff and other departments. Skilled in negotiation, able to build consensus while managing the delicate managed care relationships between system and payors.


Summarizes and analyzes rich and complex data to provide valid results and predict trends. Identifies and documents specific problems and resolution alternatives. Participates in trend and root cause analysis to identify and address recurring problems. Access computerized financial information to answer general questions as well as those related to specific accounts.Establishes and maintains productive working relationships within and outside of own area.;Uses a variety of computer hardware, operating systems, utilities and applications.Designs and interprets varied and complex financial reports. Participates in audits of specific processes or functions.Models a consistently analytical basis for decision making.Helps others to identify and work around problems that could impede progress.


This position can start at either 7:00 a.m. or 8:00 a.m. Monday through Friday.


Bachelor's degree in healthcare or business related field preferred. Experience working with Excel spreadsheets required. Minimum two years prior healthcare experience with an understanding of healthcare reimbursement preferred. Must meet standard productivity requirements prior to moving to a home-based position; if meeting productivity requirements but with less than one year working in Sanford office, must have Director approval to move to a home-based position.

About Sanford Health:

At Sanford Health, we are dedicated to the work of health and healing.

Every day, we show that commitment by delivering the highest quality of care to the communities we serve.

We are leaders in health care and strive to provide patients across the region with convenient access to expert medical care,

leading-edge technologies and world-class facilities.

In addition to strong clinical care, we are also committed to research,

education and community growth. We engage in medical research to not only discover innovative ways to provide care, but also cures for common diseases.

We continuously seek new ways to achieve our vision of improving the human condition

here in your community, across the region and around the world.

The entire team at Sanford Health recognizes the value of healthy families

and communities. We continue to gain momentum and expand our reach. Together, we can make a positive difference now, and in the future.

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 .

City: Sioux Falls

State: SD

Job Function: Revenue Cycle

Job Schedule: Full Time

Shift: Days

Req Number: WD01701