RN - Registered Nurse - Clinical Access Specialist
About The Position
As 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. 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.
Requirements
- At least three (3) years of RN work experience is required.
- Graduate from Specialty Training Program-Nursing (Required)
- Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania
Nice To Haves
- Previous experience in an acute care setting is highly preferred.
- Previous Utilization Management experience is highly preferred.
- BSN is preferred.
Responsibilities
- 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.
Benefits
- healthcare benefits for full time and part time positions from day one
- vision
- dental
- domestic partners
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
