Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. 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.
As an Finance Case Manager, you will support the Revenue Cycle department by completing retrospective reviews to ensure medical necessity is met as well as support the denial and appeal process within the Payer Denial Management department. This team is responsible for ensuring compliance, accuracy and that all possible revenue has been captured on observation accounts.
The ideal future caregiver is someone who:
*Demonstrates a strong work ethic, excellent critical thinking skills and decisive judgment.
*Thrives working both independently and as part of a team.
*Is experience with conflict resolution and problem-solving.
*Has written and verbal communication skills.
*Has organizational and multitasking skills.
*Has teamwork and motivational skills.
By taking this opportunity, you will join a team that stays connected in a remote environment with a work culture of trust, support, collaboration and acceptance.
At Cleveland Clinic, we know what matters most. That is 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 will 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 will 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 roles.
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:
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 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:
Salaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The Cleveland Clinic. Because we value each individual candidate, we invite and encourage each candidate to discuss salary/hourly specifics during the application and hiring process.
Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities
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