[Remote] Clinical Financial Case Management RN

Note: The job is a remote job and is open to candidates in USA. The Ohio State University is a prominent educational institution seeking a Clinical Financial Case Management RN to manage the operational aspects of their Revenue Cycle Clinical Support Staff. This role involves overseeing clinical pre-certification, appeals, and denial management, while ensuring compliance with healthcare regulations and supporting cash collection efforts.ResponsibilitiesResponsible for daily operational management of Revenue Cycle Clinical Support Staff, primarily involving the oversite of Clinical Pre-Certification, Peer to Peer, Clinical Appeals, Denial Analysis and Prevention for The Ohio State University Health SystemImplements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical CenterFunctions within multidisciplinary teams leading staff to secure complex pre-authorizations and prevent/appeal clinical denialsThe job duties require the utilization of clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services providedMakes determinations on the appropriate level of care (Inpatient or Observation) based on the ability to read, understand, and interpret documented clinical informationIs a Subject Matter Experts (SME) for commercial and governmental payer requirements and audits such as RAC, MAC, QIO, etcMaintains an awareness of State and National Health care trends, JCAHO, CMS, and third-party payer Utilization Management guidelinesManages 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 denialsIs 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 denialsGuides 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 appealIs versatile, flexible, and very adaptable to change because the payer rules change constantlyTroubleshoots, 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 OfficeDevelops and implements policies, procedures, workflows, and auditing proceduresServes as a resource on governmental regulatory interpretationSignificant involvement with physicians, physician leaders, and administratorsSkillsBachelor's degree in nursing with current license required2 years of relevant experience requiredExperience collaborating with physicians and their designeesStrong, proven analytical skills. Ability to make educated decisionsExtensive knowledge of clinical operations and patient flowSkilled at synthesizing large volumes of information and concisely communicating either verbally or in writingProficient in Microsoft Office Products such as: Word, Power Point, Excel, SharePoint, Teams, OneNote, etcProficient in Adobe ProfessionalProficient in using email, fax machines, copy machines, internet browsersProficient at typingProficient 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/applications2-4 years of relevant experience preferredCompany OverviewThe Ohio State University is a public research university based in Columbus, Ohio. It was founded in 1958, and is headquartered in Columbus, Ohio, USA, with a workforce of 10001+ employees. Its website is http://www.osu.edu/.