Clinical Financial Case Manager, RN

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The Ohio State University, Main Campus

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1 - 10 Mitarbeiter

Gegründet 1870

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Education

Die Ohio State University, Hauptcampus, ist eine öffentliche Forschungsuniversität in Columbus, Ohio. Sie bietet eine umfassende Ausbildung mit einer breiten Palette von Bachelor-, Master- und Berufsprogrammen an. Die Universität ist in zahlreiche Forschungsinitiativen und Partnerschaften eingebunden, die Studierenden, Dozenten und Industriepartnern die Möglichkeit zur Zusammenarbeit bieten. Ohio State fördert ein lebhaftes Studentenleben mit verschiedenen akademischen, Freizeit- und Wellnessangeboten zur Unterstützung der Bedürfnisse der Studierenden. Sie legt zudem großen Wert auf gesellschaftliches Engagement und Führungskräfteentwicklung und schafft eine inklusive Umgebung auf ihren mehreren Standorten in Ohio.

Beschreibung

• The Clinical Financial Case Manager, RN – Escalation Lead provides advanced clinical appeal services with a focused responsibility for review and escalation of complex patient account denials. • This role independently performs complex clinical reviews and evaluates relevant payer contractual terms and payer policies/guidelines to determine need for and method of escalation. • The Lead will monitor and report on commercial and governmental payer denial trends and assist in the development of denial prevention strategies, while maintaining a caseload of standard appeals as needed. • In a leadership capacity, the Lead assists the Manager as clinical and operational resource for the clinical appeals team, supporting complex case resolution, payer policy interpretation, regulatory compliance, and technology-enabled workflows. • The Lead monitors payer and regulatory updates, disseminating this information with the team. • The Lead assists the Manager in evaluating workflows for effectiveness, and in supporting the adoption of new tools and systems. • The position assists the Manager in overseeing quality of clinical appeals and provides actionable quality assurance insights to management. • The Lead also assists the Manager in monitoring productivity and performance trends. • Through collaboration, coaching, and process improvement, the Lead aligns team operations with departmental goals, payer requirements, financial performance, and organizational technology initiatives.

🎯 Anforderungen

• Bachelor’s Degree in Nursing (BSN) from an accredited nursing program. • Current, unrestricted Registered Nurse (RN) license in the applicable state of practice. • Minimum of 2 years of experience in claim denial escalation processes. • Minimum of five (5) years of experience in clinical appeals. • Minimum of five (5) years of relevant professional nursing experience, which may include utilization review, case management, prior authorization, precertification, care coordination, or related clinical revenue cycle functions. • Demonstrated working knowledge of medical necessity criteria, MCG/InterQual criteria, and governmental and commercial payer requirements. • Ability to independently review and interpret medical records, clinical documentation, and diagnostic testing to support quality assurance and payer compliance. • Proficiency in medical terminology and foundational knowledge of ICD-10 diagnosis coding and CPT/HCPCS procedural coding. • Experience using electronic health records (EHRs), payer portals, and clinical or revenue cycle technology platforms. • Effective written and verbal communication skills, including the ability to present QA findings and performance insights to leadership.

🏖️ Vorteile

• Medical, dental and vision coverage, with Ohio State paying a significant portion of the cost. • Paid time off, including sick and vacation time and 11 holidays. • State retirement plan or an alternative retirement plan, both with generous employer contributions.