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The Clinical Financial Case Manager, RN – Escalation Lead provides advanced clinical appeal services with a focused responsibility for review and escalation of complex patient account denials. This role independently performs complex clinical reviews and evaluates relevant payer contractual terms and payer policies/guidelines to determine need for and method of escalation. The Lead will monitor and report on commercial and governmental payer denial trends and assist in the development of denial prevention strategies, while maintaining a caseload of standard appeals as needed.
In a leadership capacity, the Lead assists the Manager as clinical and operational resource for the clinical appeals team, supporting complex case resolution, payer policy interpretation, regulatory compliance, and technology-enabled workflows. The Lead monitors payer and regulatory updates, disseminating this information with the team. The Lead assists the Manager in evaluating workflows for effectiveness, and in supporting the adoption of new tools and systems.
The position assists the Manager in overseeing quality of clinical appeals and provides actionable quality assurance insights to management. The Lead also assists the Manager in monitoring productivity and performance trends. Through collaboration, coaching, and process improvement, the Lead aligns team operations with departmental goals, payer requirements, financial performance, and organizational technology initiatives.
MINIMUM REQUIRED QUALIFICATIONS
Bachelor's degree or equivalent experience. Registered Nurse. 2 years of relevant experience required. 2-4 years of relevant experience preferred.
Final candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post offer process.
Thank you for your interest in positions at The Ohio State University and Wexner Medical Center. Once you have applied, the most updated information on the status of your application can be found by visiting the Candidate Home section of this site. Please view your submitted applications by logging in and reviewing your status. For answers to additional questions please review the frequently asked questions.
The university is an equal opportunity employer, including veterans and disability.
DaVita Kidney Care
ConcertoCare
BlueCross BlueShield of Tennessee
The Ohio State University Wexner Medical Center
The Ohio State University Wexner Medical Center
The Ohio State University Wexner Medical Center
The Ohio State University Wexner Medical Center
The Ohio State University Wexner Medical Center
