Clinical Specialist

2 hours ago

Philadelphia, Pennsylvania, United States Temple Health Full time
Precertification and Clinical Resource Specialist

Temple Health is seeking a highly skilled Precertification and Clinical Resource Specialist to join our team. As a key member of our PreCertification Department, you will serve as the primary clinical resource for handling complex authorization issues.

Key Responsibilities:

  • Clinically assess all adverse determinations made by insurers through all levels of the Pre-Service Administrative appeals process.
  • Support the Patient Access team to ensure precertification/authorization issues are investigated and handled expeditiously and thoughtfully from an administrative, technical, and clinical perspectives.
  • Serve as the primary liaison between the Precertification Department and staff Physicians in regard to authorization issues.
  • Review 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.

Requirements:

  • Graduate of an accredited RN program (Required)
  • 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)
  • RN-LIC - PA Registered Nurse License (Required)
  • CPUR - Cert Prof Utilization Review (Preferred)

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.

We are 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.

We are an Equal Opportunity Employer/Veterans/Disabled and welcome all qualified applicants to apply.

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