Pre-Access Clinical Specialist - RN

Why work for Nebraska Methodist Health System?At Nebraska Methodist Health System, we focus on providing exceptional care to the communities we serve and people we employ. We call it The Meaning of Care - a culture that has and will continue to set us apart. It's helping families grow by making each delivery special, conveying a difficult diagnosis with a compassionate touch, going above and beyond for a patient's needs, or giving a high five when a patient beats a disease or conquers a personal health challenge. We offer competitive pay, excellent benefits and a great work environment where all employees are valued! Most importantly, our employees are part of a team that makes a real difference in the communities we live and work in.Job Summary:Location: NMHS Corporate OfficeAddress: 825 S 169th St. - Omaha, NEWork Schedule: Mon - Fri, 8:00am to 4:30pmVerifies patient demographics, provider care plans, insurance plans/payer source, eligibility and benefits. Obtains pre-authorization according to payer guidelines, obtains or verifies medical necessity for designated procedures and imaging scans which define patient responsibility. Serves as a clinical resource to other PreAccess team members and an expert on complex medical necessity and pre-authorization cases.Responsibilities:Essential FunctionsCoordinates the pre-access process by securing pre-service medical necessity checks and pre-authorization for designated complex surgical, medical, or diagnostic imaging cases.Maintains focus on mitigating pre-service denials and peer to peer authorization reviews.Verifies eligibility and obtains benefit information.Performs medical necessity check to determine in advance if the procedure or treatment is reasonable and necessary based on diagnosis.Create cost estimates and correct payer information in the EMR as necessary.Documents/Communicates with high degree of accuracy and clarity regarding the process, completion and outcome of verification, pre-authorization and medical necessity.Uses clear communication skills and professional excellence in documentation that can be referenced by other healthcare professionals within the organization.Communicates with the Provider office staff and patient, if appropriate, with specific information when the pre-certification/authorization or medical necessity status.Maintains reference materials to ensure accuracy of information.Sets priorities that benefit the department and organizes time to complete the tasks.Can quickly adapt when new processes are introduced and/or existing processes are modified.Acts as a mentor when training them members.Serves as a clinical resource for other Pre-Access team members.Utilizes critical thinking to support team members.Supports team goals by exemplifying the team work philosophy.Shares critical information pertaining to newly discovered information or management updates.Willingness to help co-workers to accomplish department mission.Participates and takes an active role in quality assurance activities within the department.Maintains productivity and quality standards as defined through the organizational and departmental goals and objectives.Recognizes problems and informs leadership.Willing to take action when issues occur.Able to provide necessary information to other departments.Schedule:Mon - Fri, 8:00am to 4:30pmJob Description:Job RequirementsEducationGraduate of an accredited nursing program required.Bachelor of Nursing (BSN) preferred.ExperienceMinimum 3-5 years clinical experience required.Previous experience in utilization review, precertification, or case management is preferred.License/CertificationsN/ASkills/Knowledge/AbilitiesMust understand medical documentation, surgical procedures, medications, diagnostic test results, progress notes, and other medical reports.Knowledge of treatment guidelines, medical necessity and reimbursement criteria preferred.Excellent written and oral communication skills required.Must have the ability to communicate requirements to physicians, nurses, and clinical managers and gain their cooperation in the auth/pre-cert process.Must process the ability to handle intense, multiple priorities successfully and adapt quickly with an understanding of the reimbursement failure/consequences if the job is not performed correctly.Problem solving skills in an informal/formal setting necessary.Strong interpersonal and customer service skills necessary.Strong computer skills and competency with standard medical, or payer software applications required.Ability to travel to other locations within a reasonable timeframe.Physical RequirementsWeight DemandsLight Work - Exerting up to 20 pounds of force.Physical ActivityNot necessary for the position (0%):ClimbingCrawlingKneelingOccasionally Performed (1%-33%):BalancingCarryingCrouchingDistinguish colorsLiftingPulling/PushingStandingStooping/bendingTwistingWalkingFrequently Performed (34%-66%):GraspingReachingSpeaking/talkingConstantly Performed (67%-100%):Fingering/TouchingHearingRepetitive MotionsSeeing/VisualSittingJob HazardsNot Related:Chemical agents (Toxic, Corrosive, Flammable, Latex)Biological agents (primary air born and blood born viruses) (Jobs with Patient contact) (BBF)Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)Equipment/Machinery/ToolsExplosives (pressurized gas)Electrical Shock/StaticRadiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma Knife, etc)Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves that causes injuries to tissue or thermal or photochemical means)Mechanical moving parts/vibrationsAbout Methodist:Nebraska Methodist Health System is made up of four hospitals in Nebraska and southwest Iowa, more than 30 clinic locations, a nursing and allied health college, and a medical supply distributorship and central laundry facility. From the day Methodist Hospital was chartered in 1891, service to our communities has been a top priority. Financial assistance, health education, outreach to our diverse communities and populations, and other community benefit activities have always been central to our mission.Nebraska Methodist Health System is an Affirmative Action/Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation, gender identity, or any other classification protected by Federal, state or local law.