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Clinical Financial Case Manager-RN- is an area within Access and Revenue Cycle Management Shared Services responsible for denial case reviews, in-patient account validations, supporting Utilization Management, Peer to Peer processes, complex billing scenarios, audits (governmental, commercial, compliance, and internal), clinical appeals and denial management. Clinical Financial Case Manager is integral to the Revenue Cycle and supports cash collection through preventing and appealing denials.
Position Summary
The Clinical Financial Case Manager - RN (CFCM-RN) implements and supports the philosophy, mission, values, standards, policies, and procedures of The Arthur G. James Cancer Center. The CFCM-RN functions within the multidisciplinary team to 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. The CFCM-RN makes determinations on the appropriate level of care (Inpatient or Observation) based on the ability to read, understand, and interpret documented clinical information. The role requires CFCM-RNs to become Subject Matter Experts (SME) for assigned payers as well as governmental payer requirements and audits such as RAC, MAC, QIO, etc. The CFCM-RN maintains an awareness of State and National Health care trends, JCAHO, CMS, and third-party payer Utilization Management guidelines.
The Financial aspect of the role involves acquiring 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 areas that maybe needed to complete the tasks. The CFCM-RN must be able to read, understand and interpret a payer remit, denial/remark codes, and expected reimbursement to determine the cost effectiveness of completing an appeal.
The CFCM-RN must be versatile, flexible, and very adaptable to change because the payer rules change constantly. The CFCM-RN must be able to troubleshoot, problem solve, continuously learn, be highly independent, self-motivated and have an elevated level of interpretive skills and the ability to work closely with departments such as Legal, Medical Information Management, Physician groups and the Business Office.
Minimum Qualifications
Career Roadmap
FUNCTION: Finance
SUB-FUNCTION: Clinical Financial Case Management
CAREER BAND: Individual Contributor - Specialized
CAREER LEVEL: S2
Additional Information:Location:Remote LocationPosition Type:RegularScheduled Hours:40Shift:First ShiftFinal candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post offer process.Thank you for your interest in positions at The Ohio State University and Wexner Medical Center. Once you have applied, the most updated information on the status of your application can be found by visiting the Candidate Home section of this site. Please view your submitted applications by logging in and reviewing your status. For answers to additional questions please review the frequently asked questions.
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