Clinical Financial Case Manager – RN

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

📋 Description

• Execute and uphold the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center.

• Collaborate within a multidisciplinary team to obtain complex pre-authorizations and to prevent or appeal clinical denials.

• Utilize clinical expertise and medical necessity guidelines to assess the appropriateness of services.

• Identify the suitable level of care, including Inpatient or Observation, by analyzing documented clinical information.

• Serve as a Subject Matter Expert for designated payers and governmental payer requirements and audits, such as RAC, MAC, and QIO.

• Stay informed about healthcare trends, JCAHO, CMS, and third-party payer Utilization Management guidelines.

• Analyze payer remits, denial and remark codes, and anticipated reimbursement to evaluate the cost-effectiveness of appeals.

• Address issues, solve problems, continuously learn, and adapt to evolving payer regulations.

• Operate independently while closely collaborating with Legal, Medical Information Management, physician groups, and the Business Office.

• Assist with clinical pre-certification, case reviews, pre-billing edits, inpatient account validations, Utilization Management, peer-to-peer processes, billing scenarios, audits, clinical appeals, and denial management.

⛳️ Requirements

• A bachelor’s degree in nursing with a current license is required.

• At least 3 years of clinical care experience, with a focus on patient needs and comprehension of the physician’s plan of care.

• Proven experience collaborating with physicians and their representatives.

• Strong analytical abilities that have been demonstrated in practice.

• Capacity to make informed decisions.

• In-depth knowledge of clinical operations and patient flow.

• Ability to synthesize extensive information and communicate effectively, both verbally and in writing.

• Proficient in Microsoft Office applications, including Word, PowerPoint, Excel, SharePoint, Teams, and OneNote.

• Skilled in Adobe Professional.

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

• Adept typing skills.

• Proficient with technology, computers, and web applications.

• Capable of multitasking and transitioning between applications swiftly and frequently.

• Quick to orient oneself to new applications.

• Ability to manage multiple applications, including IHIS, Microsoft Office products, 3M, and payer websites/applications.

• Successful completion of a background check; a drug screening or physical may be required during the post-offer process.

🏝️ Benefits

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

• Paid time off, which includes sick and vacation time along with 11 holidays.

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

• Comprehensive benefits package.

• Commitment to equal opportunity employment, including for veterans and individuals with disabilities.