Clinical Financial Case Management - RN Specialist 2

Inside Higher Ed; Columbus (OH); On-site; USD 65,000 - 85,000; Full time

Job summary

A prominent medical institution in Columbus, Ohio is seeking a Clinical Financial Case Management - RN Specialist 2. This role involves implementing clinical pre-certification, managing denials, and supporting patient care teams. Candidates must possess a Bachelor's degree in nursing, a current RN license, and at least 3 years of clinical experience. Strong analytical and communication skills are essential along with proficiency in various software applications. The position is full-time with a regular schedule and first shift hours.

Qualifications

• Current RN license required.
• Minimum of 3 years clinical care experience with patient care.
• Experience collaborating with physicians.

Responsibilities

• Implement and support the values and procedures of the Medical Center.
• Secure complex pre-authorizations and manage clinical denials.
• Interpret medical necessity guidelines for patient services.

Skills

Analytical skills

Clinical operations knowledge

Microsoft Office proficiency

Communication skills

Problem-solving

Education

Bachelor’s degree in nursing

Tools

IHIS

Adobe Professional

MS Office products

Job description

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Job Title: Clinical Financial Case Management - RN Specialist 2

Department: Health System Shared Services | Revenue Cycle Clinical Support

Scope of Position

Revenue Cycle Clinical Support Office (RCCS) is an area within Access and Revenue Cycle Management Shared Services responsible for 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, and internal), clinical appeals and denial management. RCCS is integral to the Revenue Cycle and supports cash collection through preventing and appealing denials.

Position Summary

The Clinical Financial Case Manager - RN (CFCM-RN) implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center. The CFCM-RN functions within the multidisciplinary team to secure complex pre-authorizations and prevent/appeal clinical denials. The job duties require the utilization of clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided. The CFCM-RN makes determinations on the appropriate level of care (Inpatient or Observation) based on the ability to read, understand, and interpret documented clinical information. The role requires CFCM-RNs to become Subject Matter Experts (SME) for assigned payers as well as governmental payer requirements and audits such as RAC, MAC, QIO, etc. The CFCM-RN maintains an awareness of State and National Health care trends, JCAHO, CMS, and third-party payer Utilization Management guidelines.

The Financial aspect of the role involves acquiring knowledge of 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, etc.), Medical Information Management, Release of Information, Case Management, Utilization Management, Clinical Documentation Improvement, Compliance, Legal, Finance, Transplant workflows, Billing, Follow Up, Cash Posting, and any other areas that maybe needed to complete the tasks. The CFCM-RN must be able to read, understand and interpret a payer remit, denial/remark codes, and expected reimbursement to determine the cost effectiveness of completing an appeal.

The CFCM-RN must be versatile, flexible, and very adaptable to change because the payer rules change constantly. The CFCM-RN must be able to troubleshoot, problem solve, continuously learn, be highly independent, self-motivated and have an elevated level of interpretive skills and the ability to work closely with departments such as Legal, Medical Information Management, Physician groups and the Business Office.

Minimum Qualifications

• Bachelor’s degree in nursing with current license required.
• Minimum of 3 years clinical care experience, caring for patients, anticipating their needs, and understanding the physician’s plan of care.
• Experience collaborating with physicians and their designees.
• Strong, proven analytical skills. Ability to make educated decisions.
• Extensive knowledge of clinical operations and patient flow.
• Skilled at synthesizing large volumes of information and concisely communicating either verbally or in writing.
• Proficient in Microsoft Office Products such as: Word, Power Point, Excel, SharePoint, Teams, OneNote, etc.
• Proficient in Adobe Professional.
• Proficient in using email, fax machines, copy machines, internet browsers.
• Proficient at typing.
• Proficient in Technology, Computer, and Web applications. Must be able to multitask and move between applications quickly and frequently. Must be able to orientate self to new applications quickly. Must be able to manage complexities of having to work in multiple applications such as IHIS, MS Office products, 3M, and all payer websites/applications.

Additional Information

Location: Ackerman Rd, 660 (0242)

Position Type: Regular

Scheduled Hours: 40

Shift: First Shift

Final candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post offer process.

Thank you for your interest in positions at The Ohio State University and Wexner Medical Center. Once you have applied, the most updated information on the status of your application can be found by visiting the Candidate Home section of this site. Please view your submitted applications by logging in and reviewing your status. For answers to additional questions please review the frequently asked questions.

The university is an equal opportunity employer, including veterans and disability.

As required by Ohio Revised Code section 3345.0216, Ohio State will: educate students by means of free, open and rigorous intellectual inquiry to seek the truth; equip students with the opportunity to develop intellectual skills to reach their own, informed conclusions; not require, favor, disfavor or prohibit speech or lawful assembly; create a community dedicated to an ethic of civil and free inquiry, which respects the autonomy of each member, holds them to equal standards and provides equality of opportunity with regard to race, ethnicity, religion, sex, sexual orientation, gender identity or gender expression.