Clinical Financial Case Management RN

The Ohio State University

5d • Remote

About The Position

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. This position is responsible for the 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 for The Ohio State University Health System. It implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center. The role 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. 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 is a Subject Matter Expert (SME) for commercial and governmental payer requirements and audits such as RAC, MAC, QIO, etc. Maintains an awareness of State and National Health care trends, JCAHO, CMS, and third-party payer Utilization Management guidelines. Manages escalation processes to administration regarding the need to cancel or reschedule elective surgery when authorization is not secured along with escalations to Managed Care on payer denials. The role is a SME and leads team members in understanding critical components 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 understand how to secure authorizations and appeal/prevent denials. Guides staff on how to read, understand and interpret a payer remit, denial/remark codes, and expected reimbursement to determine the cost effectiveness of completing an appeal. The role is versatile, flexible, and very adaptable to change because the payer rules change constantly. Troubleshoots, problem solves, continuously learns, is highly independent, self-motivated and has an elevated level of interpretive skills with the ability to work closely with departments such as Legal, Medical Information Management, Physician groups and the Business Office. Develops and implements policies, procedures, workflows, and auditing procedures. Serves as a resource on governmental regulatory interpretation. Significant involvement with physicians, physician leaders, and administrators.

Requirements

• Bachelor’s degree in nursing with current license required
• 2 years of relevant experience required
• Experience collaborating with physicians and their designees
• Strong, proven analytical skills
• Ability to make educated decisions
• Extensive knowledge of clinical operations and patient flow
• Skilled at synthesizing large volumes of information and concisely communicating either verbally or in writing
• Proficient in Microsoft Office Products such as: Word, Power Point, Excel, SharePoint, Teams, OneNote, etc.
• Proficient in Adobe Professional
• Proficient in using email, fax machines, copy machines, internet browsers
• Proficient at typing
• Proficient in Technology, Computer, and Web applications
• Must be able to multitask and move between applications quickly and frequently
• Must be able to orientate self to new applications quickly
• Must be able to manage complexities of having to work in multiple applications such as IHIS, MS Office products, 3M, and all payer websites/applications

Nice To Haves

• 2-4 years of relevant experience preferred

Responsibilities

• Daily operational management of Revenue Cycle Clinical Support Staff
• Oversight of Clinical Pre-Certification, Peer to Peer, Clinical Appeals, Denial Analysis and Prevention
• Implement and support the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center
• Function within multidisciplinary teams leading staff to secure complex pre-authorizations and prevent/appeal clinical denials
• Utilize clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided
• Make determinations on the appropriate level of care (Inpatient or Observation) based on the ability to read, understand, and interpret documented clinical information
• Serve as a Subject Matter Expert (SME) for commercial and governmental payer requirements and audits
• Maintain an awareness of State and National Health care trends, JCAHO, CMS, and third-party payer Utilization Management guidelines
• Manage escalation processes to administration regarding the need to cancel or reschedule elective surgery when authorization is not secured
• Manage escalations to Managed Care on payer denials
• Lead team members in understanding critical components of Managed Care, Scheduling, Financial Counseling, Pre-Certification, Admissions/Discharges/Transfers, Clinical workflows and documentation, Revenue Management, Charge Description Master, Coding, 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 understand how to secure authorizations and appeal/prevent denials
• Guide staff on how to read, understand and interpret a payer remit, denial/remark codes, and expected reimbursement to determine the cost effectiveness of completing an appeal
• Troubleshoot, problem solve, continuously learn, and work independently
• Develop and implement policies, procedures, workflows, and auditing procedures
• Serve as a resource on governmental regulatory interpretation
• Significant involvement with physicians, physician leaders, and administrators

Benefits

• Medical, dental and vision coverage, with Ohio State paying a significant portion of the cost
• Paid time off, including sick and vacation time and 11 holidays
• State retirement plan or an alternative retirement plan, both with generous employer contributions

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level