Precert Clinical Specialist- RN License req
About The Position
Serves as the primary clinical resource in the PreCertification Department for the handling of complex authorization issues. Responsible for clinically assessing all adverse determinations made by insurers through all levels of the Pre-Service Administrative appeals process. Supports the Patient Access team (both management and staff) to ensure precertification/authorization issues are investigated and handled expeditious and thoughtfully from an administrative, technical and clinical perspectives. Serves as the primary liaison between the Precertification Department and staff Physicians in regard to authorization issues. Supports the Infusion, Radiation Therapy, Surgical, and Diagnostic Imaging Precertification Teams. Responsible for reviewing financial/insurance information obtained during the financial clearance process to determine payer requirements are met by obtaining the appropriate referrals, pre-certification/authorization for payers in order to optimize reimbursement and avoid payment penalties.
Requirements
- Graduate of an accredited RN program Required
- 3 years recent experience with Utilization Review in a hospital or in insurance company setting Required
- PA Registered Nurse License Required
Nice To Haves
- Bachelor's Degree Nursing or other clinical health care field Preferred
- 2 years experience in oncological authorization/precertification Preferred
- General Experience in working with utilization review standards Preferred
- Cert Prof Utilization Review Preferred
Responsibilities
- handling of complex authorization issues
- clinically assessing all adverse determinations made by insurers through all levels of the Pre-Service Administrative appeals process
- Supports the Patient Access team (both management and staff) to ensure precertification/authorization issues are investigated and handled expeditious and thoughtfully from an administrative, technical and clinical perspectives
- Serves as the primary liaison between the Precertification Department and staff Physicians in regard to authorization issues
- Supports the Infusion, Radiation Therapy, Surgical, and Diagnostic Imaging Precertification Teams
- Responsible for reviewing financial/insurance information obtained during the financial clearance process to determine payer requirements are met by obtaining the appropriate referrals, pre-certification/authorization for payers in order to optimize reimbursement and avoid payment penalties.
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What This Job Offers
Job Type
Full-time
Industry
Hospitals
Education Level
No Education Listed
Number of Employees
1,001-5,000 employees
