[Hiring] Clinical Financial Case Manager - RN - Escalation Lead @The Ohio State University

Role 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.

• Monitor and report on commercial and governmental payer denial trends.
• Assist in the development of denial prevention strategies.
• Maintain a caseload of standard appeals as needed.
• Assist the Manager as a clinical and operational resource for the clinical appeals team.
• Support complex case resolution, payer policy interpretation, regulatory compliance, and technology-enabled workflows.
• Monitor payer and regulatory updates, disseminating this information with the team.
• Assist the Manager in evaluating workflows for effectiveness and in supporting the adoption of new tools and systems.
• Oversee quality of clinical appeals and provide actionable quality assurance insights to management.
• Monitor productivity and performance trends.
• Align team operations with departmental goals, payer requirements, financial performance, and organizational technology initiatives through collaboration, coaching, and process improvement.

Qualifications

• Bachelor's degree or equivalent experience.
• Registered Nurse.
• 2 years of relevant experience required.
• 2-4 years of relevant experience preferred.

Requirements

• Final candidates are subject to successful completion of a background check.
• A drug screen or physical may be required during the post-offer process.

Benefits

• Remote Location.
• Regular position.
• Scheduled Hours: 40.
• Shift: First Shift.