Clinical Financial Case Management - RN

Ohio State University Wexner Medical Center; Ohio; On-site; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Clinical Financial Case Manager - RN to join their dynamic team. This role is pivotal in navigating complex pre-authorizations and managing clinical denials, requiring a deep understanding of clinical operations and payer requirements. The ideal candidate will leverage their clinical expertise and analytical skills to ensure effective appeals and contribute to the overall revenue cycle. If you thrive in a fast-paced environment and are passionate about improving patient care through financial management, this opportunity is perfect for you.

Qualifications

• 3+ years of clinical care experience in nursing.
• Strong analytical skills and ability to communicate effectively.

Responsibilities

• Manage clinical denials and secure complex pre-authorizations.
• Collaborate with multidisciplinary teams and interpret medical guidelines.

Skills

Analytical Skills

Clinical Knowledge

Communication Skills

Problem-Solving

Microsoft Office Suite

Typing Proficiency

Education

Bachelor's Degree in Nursing

Tools

IHIS

3M

Adobe Professional

Job description

Scope of Position

The Revenue Cycle Clinical Support Office (RCCS) within Access and Revenue Cycle Management Shared Services handles Clinical Pre-Certification, Case Reviews, Pre-billing edits, in-patient account validations, supporting Utilization Management, Peer-to-Peer processes, complex billing scenarios, audits (governmental, commercial, compliance, internal), clinical appeals, and denial management. RCCS plays a vital role in the Revenue Cycle, supporting cash collection by preventing and appealing denials.

Position Summary

The Clinical Financial Case Manager - RN (CFCM-RN) upholds the mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center. The CFCM-RN works within a multidisciplinary team to secure complex pre-authorizations and manage clinical denials through prevention and appeals. This role requires clinical knowledge to interpret medical necessity guidelines and determine service appropriateness. The CFCM-RN assesses the appropriate level of care (Inpatient or Observation) by interpreting clinical documentation. The role involves becoming a Subject Matter Expert (SME) for assigned payers and understanding governmental payer requirements and audits such as RAC, MAC, QIO, etc. The CFCM-RN stays informed about healthcare trends, JCAHO, CMS, and third-party payer guidelines.

The financial responsibilities include understanding Managed Care, Scheduling, Financial Counseling, Pre-Certification, Admissions/Discharges/Transfers, Clinical workflows and documentation, Revenue Management, Charge Description Master, Coding (Diagnosis, HCPCS, Revenue Codes, Procedure Codes, Modifiers), Medical Information Management, Release of Information, Case Management, Utilization Management, Clinical Documentation Improvement, Compliance, Legal, Finance, Transplant workflows, Billing, Follow-Up, Cash Posting, and other relevant areas. The CFCM-RN must interpret payor remits, denial/remark codes, and reimbursement expectations to evaluate the cost-effectiveness of appeals.

The role requires versatility, adaptability to changing payer rules, troubleshooting, problem-solving, continuous learning, independence, self-motivation, and high interpretive skills. Collaboration with Legal, Medical Information Management, Physician groups, and the Business Office is essential.

Minimum Qualifications

For Hire Required:

• Bachelor's degree in nursing with a current license.
• Minimum of 3 years of clinical care experience, including patient care, anticipating needs, and understanding physicians' plans of care.
• Experience collaborating with physicians and their designees.
• Strong analytical skills with the ability to make educated decisions.
• Extensive knowledge of clinical operations and patient flow.
• Ability to synthesize large volumes of information and communicate effectively verbally and in writing.
• Proficiency in Microsoft Office Suite (Word, PowerPoint, Excel, SharePoint, Teams, OneNote).
• Proficiency in Adobe Professional and general office equipment (email, fax, copy machines, internet browsers).
• Typing proficiency.
• Proficiency in technology, computer, and web applications, with the ability to multitask and adapt quickly to new applications such as IHIS, MS Office, 3M, and payer websites.