Clinical Financial Case Manager-RN- The James

Scope of Position

Clinical Financial Case Manager-RN- is an area within Access and Revenue Cycle Management Shared Services responsible for denial case reviews, in-patient account validations, supporting Utilization Management, Peer to Peer processes, complex billing scenarios, audits (governmental, commercial, compliance, and internal), clinical appeals and denial management.

Clinical Financial Case Manager is integral to the Revenue Cycle and supports cash collection through preventing and appealing denials.

Position Summary

The Clinical Financial Case Manager - RN (CFCM-RN) implements and supports the philosophy, mission, values, standards, policies, and procedures of The Arthur G.

James Cancer Center. The CFCM-RN functions within the multidisciplinary team to prevent / appeal clinical denials. The job duties require the utilization of clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided.

The CFCM-RN makes determinations on the appropriate level of care (Inpatient or Observation) based on the ability to read, understand, and interpret documented clinical information.

The role requires CFCM-RNs to become Subject Matter Experts (SME) for assigned payers as well as governmental payer requirements and audits such as RAC, MAC, QIO, etc.

The CFCM-RN maintains an awareness of State and National Health care trends, JCAHO, CMS, and third-party payer Utilization Management guidelines.

The Financial aspect of the role involves acquiring knowledge of Managed Care, Scheduling, Financial Counseling, Pre-Certification, Admissions / Discharges / Transfers, Clinical workflows and documentation, Revenue Management, Charge Description Master, Coding (Diagnosis, HCPCS, Revenue Codes, Procedure Codes, Modifiers, etc.

Medical Information Management, Release of Information, Case Management, Utilization Management, Clinical Documentation Improvement, Compliance, Legal, Finance, Transplant workflows, Billing, Follow Up, Cash Posting, and any other areas that maybe needed to complete the tasks.

The CFCM-RN must be able to read, understand and interpret a payer remit, denial / remark codes, and expected reimbursement to determine the cost effectiveness of completing an appeal.

The CFCM-RN must be versatile, flexible, and very adaptable to change because the payer rules change constantly. The CFCM-RN must be able to troubleshoot, problem solve, continuously learn, be highly independent, self-motivated and have an elevated level of interpretive skills and the ability to work closely with departments such as Legal, Medical Information Management, Physician groups and the Business Office.

Minimum Qualifications

• Bachelors degree in nursing with current license required.
• Minimum of 3 years clinical care experience, caring for patients, anticipating their needs, and understanding the physicians plan of care.
• Experience collaborating with physicians and their designees.
• Strong, proven analytical skills. Ability to make educated decisions.
• Extensive knowledge of clinical operations and patient flow.
• Skilled at synthesizing large volumes of information and concisely communicating either verbally or in writing.
• Proficient in Microsoft Office Products such as : Word, Power Point, Excel, SharePoint, Teams, OneNote, etc.
• Proficient in Adobe Professional Proficient in using email, fax machines, copy machines, internet browsers.
• Proficient at typing
• Proficient in Technology, Computer, and Web applications. Must be able to multitask and move between applications quickly and frequently.

Must be able to orientate self to new applications quickly. Must be able to manage complexities of having to work in multiple applications such as IHIS, MS Office products, 3M, and all payer websites / applications.

Career Roadmap

FUNCTION : Finance

SUB-FUNCTION : Clinical Financial Case Management

CAREER BAND : Individual Contributor - Specialized

CAREER LEVEL : S2