Clinical Financial Case Manager, RN

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

📋 Description

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

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

• Utilize clinical expertise to interpret and implement medical necessity guidelines.

• Assess the appropriateness of provided services.

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

• Become a subject matter expert on assigned payers and governmental payer requirements and audits, such as RAC, MAC, and QIO.

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

• Acquire and apply knowledge across various areas including managed care, scheduling, financial counseling, pre-certification, admissions/discharges/transfers, clinical workflows and documentation, revenue management, coding, medical information management, case management, utilization management, clinical documentation improvement, compliance, legal, finance, transplant workflows, billing, follow-up, and cash posting.

• Read and interpret payer remits, denial/remark codes, and anticipated reimbursement.

• Assess the cost-effectiveness of pursuing an appeal.

• Identify issues, solve problems, continuously learn, and adapt to changing payer regulations.

• Work both independently and collaboratively with Legal, Medical Information Management, physician groups, and the Business Office.

⛳️ Requirements

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

• At least 2 years of clinical care experience is necessary.

• Experience working collaboratively with physicians and their designees.

• Strong analytical skills with a proven ability to make informed decisions.

• Comprehensive knowledge of clinical operations and patient flow.

• Capability to synthesize large volumes of information and communicate clearly, both verbally and in writing.

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

• Proficiency in Adobe Professional.

• Familiarity with email, fax machines, copy machines, and internet browsers.

• Competent typing skills.

• Strong proficiency in technology, computer, and web applications.

• Ability to multitask and efficiently navigate between multiple applications.

• Quick adaptability to new applications.

• Capability to manage several applications, including IHIS, MS Office products, 3M, and payer websites/applications.

• Successful completion of a background check is required.

• A drug screen or physical may be required during the post-offer process.

🏝️ Benefits

• Regular position.

• 40 scheduled hours per week.

• First shift.

• Remote work arrangement.