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 nurses to grow their skillsets, develop their practice, and leverage their years of experience to build a rewarding, lasting career with impact. Job Duties The Clinical Access Specialist RN 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. This role is Per Diem, varied hours and work from home in the state of PA. At least three (3) years of RN work experience is required. + 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. Geisinger cares about not only its patients and members but also about you and your family. We offer a competitive compensation and benefits package to ensure that you and your loved ones can maintain good health, achieve financial stability, and excel both personally and professionally. We believe in creating a diverse and inclusive environment where all employees can be their authentic selves. To learn more: https://jobs.geisinger.org/diversity Benefits of working at Geisinger: + Full benefits (health, dental and vision) starting on day one + Three medical plan choices, including an expanded network for out-of-area employees and dependents + Pre-tax savings plans with healthcare and dependent care flexible spending accounts (FSA) and a health savings account (HSA) + Company-paid life insurance, short-term disability, and long-term disability coverage + 401(k) plan that includes automatic Geisinger contributions + Generous paid time off (PTO) plan that allows you to accrue time quickly + Up to $5,000 in tuition reimbursement per calendar year + MyHealth Rewards wellness program to improve your health while earning a financial incentive + Family-friendly support including adoption and fertility assistance, parental leave pay, military leave pay and a free Care.com membership with discounted backup care for your loved ones + Employee Assistance Program (EAP): Referrals for childcare, eldercare, & pet care. Access free legal guidance, mental health visits, work-life support, digital self-help tools and more. + Voluntary benefits including accident, critical illness, hospital indemnity insurance, identity theft protection, universal life and pet and legal insurance Position Details 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 OUR PURPOSE & VALUES: Everything we do is about caring 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 We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, from senior management on down, 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. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.