RN Clinical Access Specialist - Utilization Management

Geisinger Wilkes Barre , PA 18701

Posted 2 months ago

Job Title: RN Clinical Access Specialist - Utilization Management

Location: Wilkes-Barre, Pennsylvania

Job Category: RN - Registered Nurse, Nursing and Nursing Support

Schedule: Rotation

Work Type: Full time

Department: System Utilization Management Division

Date Posted: 09/02/2021

Job ID: R-18820

Job Summary

Are you an experienced RN looking to join our team of Healthcare Heroes? 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. Our Geisinger nurses make a difference in the lives of the people they see every day- our friends, neighbors, and family members.

Job Duties

Geisinger is hiring a RN Clinical Access Specialist for Geisinger Wyoming Valley and South Wilkes Barre Hospitals. The primary function of this role is completing Point of Entry reviews for both emergency rooms. Additionally this role performs reviews of SORU/Inpatient procedures to ensure correct operative status at the time of surgery.

  • 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.

Position Details

Work Schedule/Details:

  • Day/Evening Schedule Rotation

  • Shifts consist of 0700-1530; 0800-16:30; 1500-2330; 1100-1930

  • Monday through Friday with weekend and holiday rotation

We're proud to offer competitive salaries and a comprehensive benefits package that includes:

  • Medical, prescription drug, vision and dental coverage

  • Family Support (Fertility and Adoption Support)

  • Employer contribution to your retirement plan

  • Tuition assistance (part time and full time roles only)

  • Generous paid time off packages that allows you to take the time you need to travel, rest, and care for and reconnect with friends and family.

  • Professional opportunities for growth and advancement

  • Support and mentorship from a full range of dedicated and experienced nursing leaders

  • Paid Military Leave

  • Community Involvement through our Employee Resources Groups

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

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 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.
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RN Clinical Access Specialist - Utilization Management

Geisinger