RN - Registered Nurse - Clinical Access Specialist
Job Summary
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.
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.
Responsibilities
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
Success Profile
What makes a successful nurse at Geisinger? Check out the top traits we're looking for and see if you have the right mix.
- Collaborative
- Communicator
- Compassionate
- Problem-solver
- Team Player
- Trustworthy
Culture
Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. Our nurses treat each other with respect and compassion, embrace diversity and take time to connect and listen. We are led by five main values:
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Kindness
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Excellence
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Safety
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Learning
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Innovation
Geisinger nurses: in their own words
Hear from some members of our Geisinger team and how the fight against COVID-19 has affected them.
Our Geisinger Family
Growing up in the northeast, Geisinger has always had a reputation of being a leader in cutting edge medicine. Being part of their staff is both a privilege and honor. So far working as a RN, has been an incredible experience. The staff is knowledgeable and passionate about their field. They are always willing to help me further my education and skills.
RN, Telemetry Unit, GMC
I had a very positive experience as a student nurse during my clinical rotations and knew I wanted to join the nursing team at Geisinger Lewistown Hospital. As a new nurse everyone has been extremely helpful. My coworkers are dedicated to the success of the team and providing the best care possible for our patients.
RN, Orthopedic Oncology, GLH
I'm excited to take the lessons I've learned along my journey from bedside nurse to educator to leader and help position Geisinger's more than 6,500 nurses—in all positions, from LPNs to RNs to advanced practice nurses—for their own future successes.
Chief Nursing Executive, MSN, RN
Benefits
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Health and Wellness Programs
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Tuition Reimbursement
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Professional Development
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Maternity and Paternity Leave
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Collaboration
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Awards and Recognition
About Geisinger
Founded more than 100 years ago by Abigail Geisinger, the system now includes ten hospital campuses, a 550,000-member health plan, two research centers and the Geisinger Commonwealth School of Medicine. With nearly 24,000 employees and more than 1,700 employed physicians, Geisinger boosts its hometown economies in Pennsylvania by billions of dollars annually. Learn more at geisinger.org or connect with us on Facebook, Instagram, LinkedIn and Twitter.
Equal Opportunity Employer
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.
Our Vision & Values
Everything we do is about making better health easier for our patients, our members, our students, our Geisinger family and our communities.
KINDNESS: We strive to treat everyone as we would hope to be treated ourselves.
EXCELLENCE: We treasure colleagues who humbly strive for excellence.
LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow.
INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
SAFETY: We provide a safe environment for our patients and members and the Geisinger family.
Our Benefits
We offer healthcare benefits for full time and part time positions from day one, including vision, dental and prescription coverage.
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