Clinical Financial Case Mgr - RN

Scope of 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.

About the Role

The Clinical Financial Case Manager - RN (CFCM-RN) implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center. The CFCM-RN functions within the multidisciplinary team to secure complex pre-authorizations and prevent/appeal clinical denials. The role requires utilizing clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided. The CFCM-RN makes determinations on the appropriate level of care (Inpatient or Observation) based on documented clinical information.

The CFCM-RN becomes a Subject Matter Expert (SME) for assigned payers as well as governmental payer requirements and audits such as RAC, MAC, QIO, etc. The role involves maintaining awareness of State and National healthcare trends, JCAHO, CMS, and third-party payer Utilization Management guidelines.

The Financial aspect of the role includes acquiring knowledge 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 related areas.

The CFCM-RN must interpret payer remits, denial/remark codes, and expected reimbursement to determine the cost-effectiveness of appeals. The role requires versatility, adaptability to constant payer rule changes, troubleshooting, problem-solving, continuous learning, independence, self-motivation, and strong interpretive skills. Collaboration with departments such as Legal, Medical Information Management, Physician groups, and the Business Office is essential.

Requirements

• Bachelor’s degree in nursing with current license required.
• Minimum of 3 years clinical care experience, including anticipating patient needs and understanding the physician’s plan of care.
• Experience collaborating with physicians and their designees.
• Strong, proven analytical skills and ability to make educated decisions.
• Extensive knowledge of clinical operations and patient flow.
• Skilled at synthesizing large volumes of information and communicating concisely, verbally or in writing.
• Proficient in Microsoft Office Products (Word, PowerPoint, Excel, SharePoint, Teams, OneNote).
• Proficient in Adobe Professional, email, fax machines, copy machines, and internet browsers.
• Proficient typing skills.
• Strong technology, computer, and web application skills; ability to multitask and navigate multiple applications (e.g., IHIS, MS Office, 3M, payer websites).
• Ability to quickly learn and adapt to new applications.