REMOTE - Clinical Financial Case Management - RN Specialist 2

At The Ohio State University Wexner Medical Center you will find more than a job – you can establish a career that allows you to actually change the face of medicine. As central Ohio's only academic medical center, we emphasize learning, development and innovation in order to offer the very best in personalized care to over 1.7 million patients each year. There's plenty of opportunity for career growth too, because Ohio State's Wexner Medical Center encompasses seven hospitals, fourteen primary care offices, a walk-in clinic, two After-Hours Care locations and eleven multi-specialty clinics, as well as the College of Medicine, the School of Health and Rehabilitation Sciences, the health sciences library and the Faculty Group Practice. You'll find clinical care offered in virtually every medical specialty and subspecialty and an interdisciplinary team of healthcare experts beyond compare. Ohio State offers great pay, complete benefits, state retirement options, tuition assistance and access to the cultural and sporting resources at one of the nation’s largest universities (learn more at wexnermedical.osu.edu/careers). Outside of work, you'll discover a great quality of life. Columbus is the nation's 14th largest city with beautiful neighborhoods and a full range of activities and entertainment options. Everything we do is driven by our strategic plan, which is built on our mission to improve health in Ohio and across the world through innovation in research, education and patient care. To accomplish this, our vision calls us to push the boundaries of discovery and knowledge to solve significant problems and deliver unparalleled care. If this sounds appealing to you and you share our values of inclusiveness, determination, empathy, sincerity, ownership and innovation, Ohio State may be the perfect fit for you.

Revenue Cycle Clinical Support Office (RCCS) is an area within Access and Revenue Cycle Management Shared Services responsible for Clinical Pre-Certification, Case Reviews, Pre-billing edits, 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. RCCS is integral to the Revenue Cycle and supports cash collection through preventing and appealing denials.

The Clinical Financial Case Manager - RN (CFCM-RN) implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center. The CFCM-RN functions within the multidisciplinary team 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. 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.