[Hiring] Clinical Financial Case Management RN @The Ohio State University

Role Description

Responsible for daily operational management of Revenue Cycle Clinical Support Staff, primarily involving the oversight of:

• Clinical Pre-Certification
• Peer to Peer
• Clinical Appeals
• Denial Analysis and Prevention

Implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center. Functions within multidisciplinary teams leading staff to secure complex pre-authorizations and prevent/appeal clinical denials. The job duties require the utilization of clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided.

Key responsibilities include:

• Making determinations on the appropriate level of care (Inpatient or Observation) based on clinical information.
• Acting as a Subject Matter Expert (SME) for commercial and governmental payer requirements and audits.
• Maintaining awareness of State and National Health care trends, JCAHO, CMS, and third-party payer Utilization Management guidelines.
• Managing escalation processes regarding elective surgery authorization and payer denials.
• Leading team members in understanding critical components of Managed Care, Scheduling, Financial Counseling, and more.
• Guiding staff on interpreting payer remits, denial codes, and reimbursement expectations.
• Adapting to constant changes in payer rules.
• Troubleshooting, problem-solving, and continuously learning.
• Developing and implementing policies, procedures, workflows, and auditing procedures.
• Significant involvement with physicians, physician leaders, and administrators.

Qualifications

• Bachelor’s degree in nursing with current license required.
• 2 years of relevant experience required; 2-4 years preferred.
• Experience collaborating with physicians and their designees.
• Strong, proven analytical skills.
• Extensive knowledge of clinical operations and patient flow.
• Skilled at synthesizing large volumes of information and communicating concisely.
• Proficient in Microsoft Office Products (Word, PowerPoint, Excel, SharePoint, Teams, OneNote).
• Proficient in Adobe Professional.
• Proficient in using email, fax machines, copy machines, and internet browsers.
• Proficient at typing.
• Proficient in Technology, Computer, and Web applications.

Requirements

• Must be able to multitask and move between applications quickly.
• Must be able to orientate self to new applications quickly.
• Must manage complexities of working in multiple applications (IHIS, MS Office products, 3M, payer websites/applications).

Benefits

• Remote Location
• Regular Position Type
• Scheduled Hours: 40
• Shift: First Shift