Clinical Finance Case Management - RN
Australia, Canada, India, Ireland, Singapore, United Kingdom, United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- Minimum of 2 years clinical care experience
- Required Skills
- Analytical SkillsMicrosoft Office
Requirements
- Bachelor's degree or equivalent experience.
- Current Registered Nurse (RN) license.
- Minimum of 2 years of clinical care experience.
- Proven experience collaborating with physicians and their designees.
- Strong analytical and decision-making skills.
- Extensive knowledge of clinical operations and patient flow.
- Proficiency in Microsoft Office products (Word, PowerPoint, Excel, SharePoint, Teams, OneNote).
- Proficiency in Adobe Professional.
- Ability to multitask and navigate multiple complex applications (e.g., IHIS, 3M, payer websites).
- Ability to synthesize large volumes of information for concise communication.
Responsibilities
- Implement clinical knowledge to interpret medical necessity guidelines for service appropriateness.
- Secure complex pre-authorizations and prevent or appeal clinical denials.
- Determine appropriate level of care based on clinical documentation.
- Act as a subject matter expert for assigned payers, governmental requirements, and audits (RAC, MAC, QIO).
- Analyze payer remits, denial codes, and reimbursement data to assess appeal cost-effectiveness.
- Collaborate with Legal, Medical Information Management, physician groups, and the Business Office.
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