Clinical Finance Case Management – RN

This is a fully remote position, open to applicants in United States.

📋 Description

• The Clinical Financial Case Manager - RN (CFCM-RN) executes and enhances the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center.

• The CFCM-RN collaborates within a multidisciplinary team to obtain complex pre-authorizations and to prevent or appeal clinical denials.

• Job responsibilities necessitate the use of clinical expertise to interpret and apply medical necessity guidelines for assessing the appropriateness of services rendered.

• The CFCM-RN evaluates the suitable level of care (Inpatient or Observation) by effectively reading, comprehending, and interpreting documented clinical data.

• This position requires CFCM-RNs to become Subject Matter Experts (SME) for designated payers as well as for governmental payer requirements and audits such as RAC, MAC, QIO, etc.

• The CFCM-RN stays informed about State and National healthcare trends, JCAHO, CMS, and third-party payer Utilization Management guidelines.

• The financial responsibilities of the role include gaining 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 necessary areas to complete tasks.

• The CFCM-RN must possess the ability to read, comprehend, and interpret payer remits, denial/remark codes, and anticipated reimbursements to assess the cost-effectiveness of pursuing an appeal.

• The CFCM-RN should be versatile, flexible, and highly adaptable to change due to the ever-evolving nature of payer regulations.

• The role requires the CFCM-RN to be capable of troubleshooting, problem-solving, continuous learning, working independently, self-motivation, and possessing a high level of interpretive skills, along with the ability to collaborate closely with departments such as Legal, Medical Information Management, Physician groups, and the Business Office.

⛳️ Requirements

• Bachelor's degree or equivalent experience.

• Registered Nurse.

• A minimum of 2 years of clinical care experience, providing care to patients, anticipating their needs, and understanding the physician’s plan of care.

• Experience working collaboratively with physicians and their designees.

• Strong, demonstrated analytical skills.

• Extensive knowledge of clinical operations and patient flow.

• Proficient at synthesizing large volumes of information and communicating effectively, either verbally or in writing.

• Proficient in Microsoft Office Products including Word, PowerPoint, Excel, SharePoint, Teams, OneNote, etc.

• Proficient in Adobe Professional.

• Skilled in using email, fax machines, copy machines, and internet browsers.

• Competent in typing.

• Proficient in Technology, Computer, and Web applications.

• Must possess the ability to multitask and transition quickly and frequently between applications.

• Must be adept at quickly orienting oneself to new applications.

• Must be capable of managing the complexities of working across multiple applications such as IHIS, MS Office products, 3M, and various payer websites/applications.

🏝️ Benefits

• Medical, dental, and vision coverage, with Ohio State covering a significant portion of the cost.

• Paid time off, including sick leave, vacation time, and 11 holidays.

• State retirement plan or an alternative retirement plan, both offering generous employer contributions.