Payer Denial Management Nurse: Supports the denial and appeal process within the Payer Denial Management department. Coordinates denial appeal follow-up and analyzes provided clinical documentation, criteria application, physician advisor input, completes review of the medical record and formulates the appeal letter. Participates in the application of medical necessity review and utilizes criteria tool (MCG and/or Inter. Qual). Ensures compliance standards are met with required elements and prov... more details
At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.
We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.
Job Title
Finance Case Manager
Location
Independence
Facility
CC Business Operations Ctr
Department
RCM Payor Denial Mgmt-Finance
Job Code
T99262
Shift
Days
Schedule
7:00am-3:30pm
Job Summary
Job Details
Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will work alongside passionate and dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.
We are looking for a Finance Case Manager to join our dedicated team of caregivers. Our team prides itself on our character and integrity. As a Finance Case Manager, your decisions will be guided by our ‘Patients First’ philosophy. Each decision you make can impact our patients financially, and our team always works with patients in mind. Your duties will include:
• Supporting the revenue cycle by completing retrospective reviews to ensure medical necessity criteria is met.
• Assuring enterprise activities conform to regulatory requirements and identifying trends, process opportunities to maximize reimbursement.
• Supporting policy development and interdisciplinary education.
Our ideal caregiver is someone who:
• Is self-motivated and positive.
• Can work independently and adapts to change.
This role allows you to work from home and gives you the opportunity to join special projects and committees.
At Cleveland Clinic, we know what matters most. That's why we treat our caregivers as if they are our own family, and we are always creating ways to be there for you. Here, you'll find that we offer: resources to learn and grow, a fulfilling career for everyone, and comprehensive benefits that invest in your health, your physical and mental well-being and your future. When you join Cleveland Clinic, you'll be part of a supportive caregiver family that will be united in shared values and purpose to fulfill our promise of being the best place to receive care and the best place to work in healthcare.
Responsibilities:
- Payer Denial Management Nurse: Supports the denial and appeal process within the Payer Denial Management department. Coordinates denial appeal follow-up and analyzes provided clinical documentation, criteria application, physician advisor input, completes review of the medical record and formulates the appeal letter. Participates in the application of medical necessity review and utilizes criteria tool (MCG and/or InterQual). Ensures compliance standards are met with required elements and provides feedback to the management team. Relays physician, nursing and care manager documentation improvement opportunities to assist with appeal defense process.
- RAC /Payer Audit Nurse: Supports denials, appeals, within the Payer Audit department. Conducts audit reviews to assure activities conform to regulatory requirements. Coordinates denial appeal follow-up; analyzes provided clinical documentation, criteria application outcome, physician advisor input, completes review of the medical record and formulates the appeal letter. Expert in the application of medical necessity review criteria tool (MCG and/or InterQual). Supports the development of performance improvement strategies in response to identified patterns and trends involving government payers.
- Charge Capture Nurse: Supports the Observation charge capture process for the enterprise. Works with a multi-disciplinary team to evaluate and improve the charge capture process. Reviews the medical record for Observation cases to ensure accurate and timely billing of observation hours and appropriate charges. Utilizes the application of medical necessity review criteria tool (MCG and/or InterQual). Works cooperatively to review, evaluate and improve the charge capture process to establish an enterprise uniform process. Supports development of performance improvement strategies in response to identified patterns and trends.
- Other duties as assigned.
Education:
- Bachelor of Science in Nursing or Bachelor's degree in a related field preferred.
Certifications:
- Licensed Registered Nurse (RN) in the state of Ohio, BSN preferred.
- Professional certification as a Case Manager preferred.
- Expertise with InterQual and Milliman disease management ideologies preferred.
Complexity of Work:
- Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
- Must be able to work in a stressful environment and take appropriate action.
Work Experience:
- Minimum 3-5 years Care Management or Utilization experience which would include acute med/surg, ICU, or ER experience required.
- Expertise with InterQual and Milliman disease management ideologies is preferred.
- In-depth familiarity with third party billing requirement and regulations, billing documentation requirements preferred.
- Understanding of CPT and HCPCS coding guidelines preferred.
Physical Requirements:
- Manual dexterity to operate office equipment.
- Requires extended periods of standing, walking, sitting and carrying up to 10 pounds.
- Normal or corrected vision and hearing to normal range.
Personal Protective Equipment:
- Follows standard precautions using personal protective equipment as required.
The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. All offers of employment are follwed by testing for controlled substances and nicotine. All new caregivers must clear a nicotine test within their 90-day new hire period. Candidates for employment who are impacted by Cleveland Clinic Health System's Smoking Policy will be permitted to reapply for open positions after one year.
Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.
Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility.
Please review the Equal Employment Opportunity poster.
Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities