Clinical Financial Case Management RN
Core
Oversees daily operations of Revenue Cycle Clinical Support staff, managing clinical pre-certification, peer-to-peer reviews, and denial analysis/prevention to secure authorizations and prevent billing denials for The Ohio State University Health System.
Role type
Senior Clinical Financial Case Management RN (Revenue Cycle Operations Lead)
Builds
Operational workflows for clinical pre-certification, utilization management, and denial prevention
Domain
Healthcare Revenue Cycle / Clinical Operations / Managed Care Compliance
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical nursing expertise, Utilization Management, Medical necessity guidelines interpretation, Payer audit compliance (RAC/MAC/QIO), Denial analysis and appeal strategy, Team leadership, Regulatory interpretation (CMS/JCAHO), Coding knowledge (Diagnosis/HCPCS/Revenue/Procedure codes), Financial counseling, Workflow optimization
Preferred skills
Experience with complex billing scenarios, Knowledge of transplant workflows, Proficiency in payer websites and applications, Background check clearance
Technologies
IHIS, 3M, Microsoft Office (Word, Excel, PowerPoint, SharePoint, Teams, OneNote), Adobe Professional, Email/Fax systems
Responsibilities
Lead staff in securing complex pre-authorizations and preventing/appealing clinical denials, Interpret clinical documentation to determine appropriate levels of care, Serve as SME for commercial and governmental payer requirements and audits, Develop and implement policies and auditing procedures, Collaborate with physicians, legal, and business office departments, Manage escalations regarding authorization cancellations and payer denials