Clinical Financial Case Manager, RN

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🕒 June 10

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The Ohio State University, Main Campus

WebsiteLinkedInAll Job Openings

1 - 10 employees

Founded 1870

📚 Education

Education

The Ohio State University, Main Campus is a public research university located in Columbus, Ohio. It offers a comprehensive education with a wide array of undergraduate, graduate, and professional programs. The university is engaged in numerous research initiatives and partnerships, providing opportunities for students, faculty, and industry partners to collaborate. Ohio State promotes a vibrant student life with various academic, recreational, and wellness services to support student needs. It also emphasizes community involvement and leadership development, fostering an inclusive environment on its multiple campuses across Ohio.

📋 Description

• 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.

🎯 Requirements

• 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.

🏖️ Benefits

• 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.