RN, Registered Nurse – Clinical Access Specialist, Per Diem

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Conduct initial, concurrent, and retrospective reviews of medical records to determine medical necessity and appropriate level of care.

• Ensure compliance with certification requirements set by state, federal, and third-party payers.

• Identify and inform relevant staff about discrepancies in health insurance coverage from third-party payers and any lack of coverage.

• Keep up-to-date with third-party payer health plans, nationally recognized review standards, as well as state and federal regulations.

• Analyze cases and carry out precertification tasks as per third-party payer agreements.

• Evaluate admission requests for appropriateness of level of care and adherence to certification criteria and ambulatory procedures.

• Request further clinical information and documentation when criteria for medical necessity are not satisfied.

• Provide insights, propose alternatives, and support documentation accuracy.

• Input utilization review data into databases for monitoring, trending audits, billing, reimbursement, and Medicare compliance.

• Report serious incidents and events in accordance with hospital policies and procedures.

• Maintain the integrity of medical necessity chart reviews and ensure proper application of review standards.

• Serve as a resource for the healthcare team on payer benefits and transitions to the next level of care or discharge to home.

• Work flexible hours during the week or weekend in a per diem capacity.

⛳️ Requirements

• Graduate from a Specialty Training Program in Nursing (Required).

• Minimum of 3 years of nursing experience (Required).

• Licensed Registered Nurse in Pennsylvania (Required).

• Acute care experience is preferred.

• Prior Utilization Management experience is highly preferred.

• BSN is preferred.

• Familiarity with third-party payer health plans.

• Understanding and application of nationally recognized review criteria.

• Knowledge of relevant state and federal regulations and mandates.

• Capability to execute medical necessity and level-of-care reviews.

• Ability to conduct precertification reviews under payer contracts.

• Proficient in using databases for tracking utilization reviews, audits, billing, reimbursement, and Medicare compliance.

• Must be able to work flexible hours on weekdays or weekends.

• Must fulfill job-specific responsibilities and adhere to organizational policies and procedures.

🏝️ Benefits

• Comprehensive benefits package (health, dental, and vision) effective from day one.

• Three medical plan options, including an expanded network for employees and dependents located outside the area.

• Pre-tax savings plans with healthcare and dependent care flexible spending accounts (FSA) and a health savings account (HSA).

• Company-sponsored life insurance, short-term disability, and long-term disability coverage.

• 401(k) plan inclusive of automatic contributions from Geisinger.

• Generous paid time off (PTO) system that allows for rapid accrual of time.

• Up to $5,000 in tuition reimbursement available each calendar year.

• MyHealth Rewards wellness program offering financial incentives.

• Assistance with adoption and fertility.

• Paid parental leave.

• Paid military leave.

• Complimentary Care.com membership with discounted backup care options.

• Employee Assistance Program (EAP) providing childcare, eldercare, pet care referrals, free legal advice, mental health sessions, work-life support, and digital self-help resources.

• Optional benefits including accident, critical illness, hospital indemnity insurance, identity theft protection, universal life, pet, and legal insurance.

• Healthcare benefits available for both full-time and part-time roles from day one, including vision, dental, and domestic partner benefits.

• A collaborative, cooperative, and collegial work environment.