Clinical Authorization Specialist

2 weeks ago


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

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 to ensure precertification/authorization issues are investigated and handled expeditiously 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.

Requirements
  • Graduate of an accredited RN program (Required)
  • Bachelors Degree in Nursing or other clinical healthcare field (Preferred)
  • 3 Years recent experience with Utilization Review in a hospital or insurance company setting (Required)
  • 2 Years experience in oncological authorization/precertification (Preferred)
  • General experience in working with utilization review standards (Preferred)
  • PA Registered Nurse License (Required)
  • Certified Professional Utilization Review (Preferred)


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