Clinical Financial Case Manager - RN - Escalation Lead

The Ohio State University

4d • Remote

About The Position

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. The Lead will monitor and report on commercial and governmental payer denial trends and assist in the development of denial prevention strategies, while maintaining a caseload of standard appeals as needed. In a leadership capacity, the Lead assists the Manager as clinical and operational resource for the clinical appeals team, supporting complex case resolution, payer policy interpretation, regulatory compliance, and technology-enabled workflows. The Lead monitors payer and regulatory updates, disseminating this information with the team. The Lead assists the Manager in evaluating workflows for effectiveness, and in supporting the adoption of new tools and systems. The position assists the Manager in overseeing quality of clinical appeals and provides actionable quality assurance insights to management. The Lead also assists the Manager in monitoring productivity and performance trends. Through collaboration, coaching, and process improvement, the Lead aligns team operations with departmental goals, payer requirements, financial performance, and organizational technology initiatives.

Requirements

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

Nice To Haves

• 2-4 years of relevant experience preferred.

Responsibilities

• Provides advanced clinical appeal services with a focused responsibility for review and escalation of complex patient account denials.
• Independently performs complex clinical reviews and evaluates relevant payer contractual terms and payer policies/guidelines to determine need for and method of escalation.
• Monitors and reports on commercial and governmental payer denial trends and assists in the development of denial prevention strategies.
• Maintains a caseload of standard appeals as needed.
• Assists the Manager as clinical and operational resource for the clinical appeals team, supporting complex case resolution, payer policy interpretation, regulatory compliance, and technology-enabled workflows.
• Monitors payer and regulatory updates, disseminating this information with the team.
• Assists the Manager in evaluating workflows for effectiveness, and in supporting the adoption of new tools and systems.
• Assists the Manager in overseeing quality of clinical appeals and provides actionable quality assurance insights to management.
• Assists the Manager in monitoring productivity and performance trends.
• Aligns team operations with departmental goals, payer requirements, financial performance, and organizational technology initiatives through collaboration, coaching, and process improvement.

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: Senior