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Job Summary

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 dataa 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.

Job Duties

• 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

• Hours: Rotation to be reviewed at interview (7a to 3p, 11a to 7p and 3p to 11p)
• Travel: Less than 25%. Minimal travel
• Prior experience: Preferred experience in Utilization Review, Care / Case Management or Nurse Reviewer at an insurance company
• Weekends/On-call/Holidays: rotation to be reviewed at interview
• Work location: Hybrid model - in person at Geisinger Medical Center and ability to work from home - Please note that you must be willing to work in person in Danville, PA. This position is not 100% remote.

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At Geisinger, the caring that we provide to our patients and members also extends to you and your family. Our competitive compensation and benefits package helps you and your loved ones stay healthy, meet your financial goals and thrive professionally and personally.

• Benefits: Geisinger offers a comprehensive suite of healthcare benefits, including medical, prescription drug, vision and dental coverage. And with our healthcare benefits, you'll also receive care from one of the top innovative healthcare systems in the country. Our suite of benefits supports you and your family in a variety of ways, including coverage for same-sex or opposite-sex spouses, domestic partners and their children and stepchildren.
• Paid Time Off: Our generous paid-time-off packages allow you to take the time you need to travel, rest, and care for and reconnect with friends and family. We also offer paid military and parental leave.
• Diversity and Inclusion: We strive to create an environment where our patients, health plan members and employees can be their most authentic selves. Join one of our many Employee Resource Groups (ERGs). ERGs provide opportunities for all Geisinger employees to build internal and external networks and further develop professionally. ERGs are formed around common identities but are open to all employees.
• Tuition Assistance: Up to $5,000 tuition reimbursement: We offer tuition reimbursement towards both undergraduate and graduate degrees.(Part time and Full Time Positions only)
• Retirement: We contribute 5% of your salary to your retirement plan and offer auto-enrollment to make saving convenient for you.

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.