Location:
Work from home (Pennsylvania)
Shift:
Days (United States of America)
Scheduled Weekly Hours:
40
Worker Type:
Regular
Exemption Status:
YesAs one of the Top 8 Most Innovative Healthcare Systems in Becker’s Hospital Review, we’re working to create a national model for improving health. Today, we’re focused on bringing our region services that improve every facet of life to drive total health, inside and out.
Through professional growth, quality improvement, and interdisciplinary collaboration, we’ve built an innovative culture that allows for growth of your skillsets and the opportunity to leverage your years of experience to build a rewarding, lasting career with impact.
Job Duties:
The Clinical Access Specialist RN performs utilization review, medical necessity assessments, and authorization activities to promote quality outcomes, timely reimbursement, and effective care transitions. Responsibilities include reviewing clinical documentation, verifying coverage and certification requirements, collaborating with physicians and care teams, and serving as a resource on payer guidelines and discharge planning. The Clinical Access Specialist maintains accurate utilization review records, supports documentation integrity, and helps ensure compliance with state, federal, and third-party payer standards.
At least three (3) years of RN work experience is required.
Previous experience in an acute care setting is highly preferred.
Previous Utilization Management experience is highly preferred.
BSN is preferred.
A typical schedule is 7:30 am to 4 pm with some evening, weekend and holiday rotation.
Position Details:
Performs and ensures adherence to state, federal and third party payer certification requirements for initial, concurrent and retrospective medical record review for medical necessity and level of care determination. Identifies and notifies appropriate staff regarding discrepancy issues with third party payer health insurance coverage and lack of coverage. Maintains a working knowledge of third party payer health plans, working knowledge of nationally recognized review criteria and its application and state and federal regulations and mandates. Reviews cases, using standard parameters, in order to perform precertification requirements as indicated in third party payer contracts. Reviews all admission requests for appropriateness of level of care and compliance with third party pre-admission certification requirements, regulatory and standard ambulatory procedures. Requests additional clinical information and documentation when request does not meet medical necessity for level of care requested. Provides information, suggests alternatives and assists in ensuring documentation integrity. Enters utilization review data into database for tracking and trending audits, billing and reimbursement and Medicare compliance requirements. Reports serious events and incidents in accordance with established hospital policy and procedure. Attends to and ensures to the utmost integrity of the medical necessity chart review and application of review requirements. Acts a resource person for the healthcare team regarding third party payer health plan benefits for transition to next level of care or discharge to home.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Education:
Graduate from Specialty Training Program-Nursing (Required)
Experience:
Minimum of 3 years-Nursing (Required)
Certification(s) and License(s):
Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania
Skills:
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities.
We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality.
We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.
Geisinger is among the nation’s leading providers of value-based care, serving 1.2 million people in urban and rural communities across Pennsylvania. Founded in 1915 by philanthropist Abigail Geisinger, the nonprofit system generates $10 billion in annual revenues across 126 care sites — including 10 hospital campuses — and Geisinger Health Plan, with more than half a million members in commercial and government plans. Geisinger College of Health Sciences educates more than 5,000 medical professionals annually and conducts more than 1,400 clinical research studies.
With 26,000 employees, including 1,700 employed physicians, Geisinger is among Pennsylvania’s largest employers with an estimated economic impact of $15 billion to the state’s economy. On March 31, 2024, Geisinger became the first member of Risant Health, a new nonprofit charitable organization created to expand and accelerate value-based care across the country.
For more information, visit geisinger.org/careers or connect with us on Facebook, Instagram, LinkedIn and Twitter.
