Clinical Financial Case Mgr - RN

The Ohio State University

17h • Remote

About The Position

The Clinical Financial Case Manager - RN (CFCM-RN) works within the multidisciplinary team to secure complex pre-authorizations and prevent or appeal clinical denials. The role applies clinical knowledge and medical necessity guidelines to assess the appropriateness of services and determine the appropriate level of care, including inpatient or observation, based on documented clinical information. The CFCM-RN develops subject matter expertise for assigned payers and governmental payer requirements and audits, and stays aware of healthcare trends and utilization management guidelines from JCAHO, CMS, and third-party payers.

The financial responsibilities involve learning and applying knowledge across managed care, scheduling, financial counseling, pre-certification, patient flow and clinical documentation, revenue management, coding, medical information management, release of information, case management, utilization management, clinical documentation improvement, compliance, legal and finance, transplant workflows, billing, follow-up, and cash posting. The CFCM-RN interprets payer remittances, denial and remark codes, and expected reimbursement to assess whether an appeal is cost effective.

The position requires adaptability as payer rules change, troubleshooting and problem-solving skills, continuous learning, independence, self-motivation, and strong interpretive skills. The CFCM-RN works closely with Legal, Medical Information Management, physician groups, and the Business Office.

Requirements

• Bachelor’s degree in nursing and a current nursing license.
• At least 2 years of clinical care experience, including caring for patients, anticipating their needs, and understanding the physician’s plan of care.
• Experience collaborating with physicians and their designees.
• Strong, proven analytical skills and the ability to make educated decisions.
• Extensive knowledge of clinical operations and patient flow.
• Ability to synthesize large volumes of information and communicate concisely verbally or in writing.
• Proficiency with Microsoft Office products, including Word, PowerPoint, Excel, SharePoint, Teams, and OneNote.
• Proficiency with Adobe Professional, email, fax machines, copy machines, and internet browsers.
• Proficient typing skills.
• Proficiency with technology, computers, and web applications; ability to multitask across applications, learn new applications quickly, and work across systems such as IHIS, Microsoft Office, 3M, and payer websites or applications.
• Ability to work independently, stay self-motivated, adapt to change, and continuously learn.

Responsibilities

• Secure complex pre-authorizations.
• Prevent and appeal clinical denials.
• Interpret medical necessity guidelines and clinical documentation to determine appropriateness of services and the appropriate level of care, including inpatient or observation.
• Develop subject matter expertise for assigned payers and governmental payer requirements and audits, including RAC, MAC, and QIO.
• Maintain awareness of healthcare trends and JCAHO, CMS, and third-party payer utilization management guidelines.
• Use knowledge of financial, clinical, revenue cycle, coding, billing, and related workflows to complete assigned tasks.
• Interpret payer remittances, denial and remark codes, and expected reimbursement to determine the cost effectiveness of appeals.
• Troubleshoot and solve problems, adapt to changing payer rules, and collaborate with Legal, Medical Information Management, physician groups, and the Business Office.

What This Job Offers

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