RN - Registered Nurse - Clinical Access Specialist

Job Duties

• Reviews clinical documentation
• Verifies coverage and certification requirements
• Collaborates with physicians and care teams
• Serves as a resource on payer guidelines and discharge planning

Requirements

• At least three (3) years of RN work experience
• Previous experience in an acute care setting highly preferred
• Previous Utilization Management experience highly preferred
• Bachelor of Science in Nursing (BSN) preferred

Position Details

• Performs and ensures adherence to state, federal and third party payer certification requirements
• 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, nationally recognized review criteria, 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
• 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 as 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

Education

• Graduate from Specialty Training Program-Nursing

Experience

• Minimum of 3 years-Nursing

Certification(s) and License(s)

• Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania

Position Details

• Typical schedule is 7:30 am to 4 pm with some evening, weekend and holiday rotation