Precert Clinical Specialist- RN License req

Temple Health – Temple University Health System; Philadelphia (Philadelphia County); On-site; USD 49,000 - 80,000; Full time

Job summary

Join a dynamic team at a leading health system as a Precert Clinical Specialist. This role focuses on handling complex authorization issues while collaborating with medical staff to ensure efficient processes. Ideal candidates will have significant experience with Utilization Review and an RN license, and they will play a crucial part in optimizing patient care and reimbursement processes.

Qualifications

• 3 Years recent experience with Utilization Review in a hospital or insurance setting.
• 2 Years Experience In Oncological Authorization/precertification preferred.

Responsibilities

• Serves as primary clinical resource for handling complex authorization issues.
• Supports Patient Access team to investigate precertification/authorization issues.

Skills

Utilization Review

Clinical Assessment

Education

Graduate of an accredited RN program

Bachelors Degree in Nursing or other clinical health care field

Job description

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Serves as the primary clinical resource in the PreCertification Department for the handling of complex authorization issues. Responsible for clinically assessing all adverse determinations made by insurers through all levels of the Pre-Service Administrative appeals process. Supports the Patient Access team (both management and staff) to ensure precertification/authorization issues are investigated and handled expeditious and thoughtfully from an administrative, technical and clinical perspectives. Serves as the primary liaison between the Precertification Department and staff Physicians in regard to authorization

issues. Supports the Infusion, Radiation Therapy, Surgical, and Diagnostic Imaging Precertification Teams. Responsible for reviewing financial/insurance information obtained during the financial clearance process to determine payer requirements are met by obtaining the appropriate referrals, pre-certification/authorization for payers in order to optimize reimbursement and avoid payment penalties.


Education

Other : Graduate of an accredited RN program (Required)

Bachelors Degree : Nursing or other clinical health care field (Preferred)


Experience

3 Years recent experience with Utilization Review in a hospital or in insurance company setting (Required)


2 Years Experience In Oncological Authorization/precertification (Preferred)

General Experience in working with utilization review standards (Preferred)

License/Certifications

RN-LIC - PA Registered Nurse License (Required)


CPUR - Cert Prof Utilization Review (Preferred)

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Your Tomorrow is Here!

Temple Health is a dynamic network of outstanding hospitals, specialty centers, and physician practices that is advancing the fight against disease, pushing the boundaries of medical science, and educating future healthcare professionals. Temple Health consists of Temple University Hospital (TUH), Fox Chase Cancer Center, TUH-Jeanes Campus, TUH-Episcopal Campus, TUH-Northeastern Campus, Temple Physicians, Inc., and Temple Transport Team. Temple Health is proudly affiliated with the Lewis Katz School of Medicine at Temple University.

To support this mission, Temple Health is continuously recruiting top talent to join its diverse, 10,000 strong workforce that fosters a healthy, safe and productive environment for its patients, visitors, students and colleagues alike. At Temple Health, your tomorrow is here!


Equal Opportunity Employer/Veterans/Disabled

An Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.

Your Tomorrow is Here!

Temple Health is committed to setting new standards for preventing, diagnosing and treating major diseases in our community and across the nation. Achieving that goal means investing in our employees' success through staff and leadership development. Our recruitment strategy is to attract and retain a diverse, high performing workforce that fosters a healthy, safe and productive environment for our patients and colleagues alike.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care

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