Provides advanced clinical appeal services with a focused responsibility for review and escalation of complex patient account denials.
Independently performs complex clinical reviews and evaluates relevant payer contractual terms and payer policies/guidelines to determine need for and method of escalation.
Monitors and reports on commercial and governmental payer denial trends and assists in the development of denial prevention strategies, while maintaining a caseload of standard appeals as needed.
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.
Monitors payer and regulatory updates, disseminating this information with the team.
Assists the Manager in evaluating workflows for effectiveness, supporting the adoption of new tools and systems.
Assists the Manager in overseeing quality of clinical appeals and provides actionable quality assurance insights to management.
Monitors productivity and performance trends.

Bachelor’s Degree in Nursing (BSN) from an accredited nursing program.
Current, unrestricted Registered Nurse (RN) license in the applicable state of practice.
Minimum of 2 years of experience in claim denial escalation processes.
Minimum of five (5) years of experience in clinical appeals.
Minimum of five (5) years of relevant professional nursing experience, which may include utilization review, case management, prior authorization, precertification, care coordination, or related clinical revenue cycle functions.
Demonstrated working knowledge of medical necessity criteria, MCG/InterQual criteria, and governmental and commercial payer requirements.
Ability to independently review and interpret medical records, clinical documentation, and diagnostic testing to support quality assurance and payer compliance.
Proficiency in medical terminology and foundational knowledge of ICD-10 diagnosis coding and CPT/HCPCS procedural coding.
Experience using electronic health records (EHRs), payer portals, and clinical or revenue cycle technology platforms.
Effective written and verbal communication skills, including the ability to present QA findings and performance insights to leadership.

Medical, dental and vision coverage, with Ohio State paying a significant portion of the cost.
Paid time off, including sick and vacation time and 11 holidays.
State retirement plan or an alternative retirement plan, both with generous employer contributions.

Clinical Financial Case Manager, RN

Key skills