The Ohio State University Wexner Medical Center · 1 day ago
Clinical Financial Case Management - RN Specialist 2
Columbus, OH
Full-time
Onsite
Mid Level
3+ years expThe Ohio State University Wexner Medical Center is seeking a Clinical Financial Case Manager - RN Specialist. The CFCM-RN role involves securing complex pre-authorizations, preventing clinical denials, and utilizing clinical knowledge to interpret medical necessity guidelines while working within a multidisciplinary team.
Health CareHospitalMedical
Responsibilities
Implement and support the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center
Function within the multidisciplinary team to secure complex pre-authorizations and prevent/appeal clinical denials
Utilize clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided
Make determinations on the appropriate level of care (Inpatient or Observation) based on the ability to read, understand, and interpret documented clinical information
Become Subject Matter Experts (SME) for assigned payers as well as governmental payer requirements and audits such as RAC, MAC, QIO, etc
Maintain an awareness of State and National Health care trends, JCAHO, CMS, and third-party payer Utilization Management guidelines
Acquire 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 any other areas that maybe needed to complete the tasks
Read, understand and interpret a payer remit, denial/remark codes, and expected reimbursement to determine the cost effectiveness of completing an appeal
Be versatile, flexible, and very adaptable to change because the payer rules change constantly
Troubleshoot, problem solve, continuously learn, be highly independent, self-motivated and have an elevated level of interpretive skills and the ability to work closely with departments such as Legal, Medical Information Management, Physician groups and the Business Office
Qualification
Required
Bachelor's degree in nursing with current license required
Minimum of 3 years clinical care experience, 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. Ability to make educated decisions
Extensive knowledge of clinical operations and patient flow
Skilled at synthesizing large volumes of information and concisely communicating either verbally or in writing
Proficient in Microsoft Office Products such as: Word, Power Point, Excel, SharePoint, Teams, OneNote, etc
Proficient in Adobe Professional
Proficient in using email, fax machines, copy machines, internet browsers
Proficient at typing
Proficient 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/applications
Company
The Ohio State University Wexner Medical Center
The Ohio State University Wexner Medical Center is personalizing health care to meet the needs of each patient. It is a sub-organization of The Ohio State University.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Emile Daoud
Chief, Cardiac Electrophysiology Section
Recent News
2025-10-09
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