Finance Case Manager

Finance Case Manager  

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.    

As a Finance Case Manager, you will support the department by completing retrospective reviews to ensure medical necessity criteria is met, ensure enterprise activities conform to regulatory requirements, identify trends and process opportunities to maximize reimbursement, and support policy development and interdisciplinary education. 

A caregiver in this position works 8:00am—5:00pm.  

A caregiver who excels in this role will:  

• Payer Denial Management Nurse:  

• Support the denial and appeal process within the Payer Denial Management department.  

• Coordinate denial appeal follow-up and analyze provided clinical documentation, criteria application and physician advisor input. 

• Complete review of the medical record and formulate the appeal letter.  

• Participate in the application of medical necessity review and utilize criteria tools (MCG and/or InterQual).  

• Ensure compliance standards are met with required elements and provide feedback to the management team.  

• Relay physician, nursing and care manager documentation improvement opportunities to assist with appeal defense process. 

• RAC/Payer Audit Nurse:  

• Support denials and appeals within the Payer Audit department.  

• Conduct audit reviews to ensure activities conform to regulatory requirements. 

• Coordinate denial appeal follow-up. 

• Analyze provided clinical documentation, criteria application outcome and physician advisor input. 

• Complete review of the medical record and formulate the appeal letter.  

• Be an expert in the application of medical necessity review criteria tools (MCG and/or InterQual). 

• Support the development of performance improvement strategies in response to identified patterns and trends involving government payers. 

• Charge Capture Nurse:  

• Support the observation charge capture process for the enterprise.  

• Work with a multi-disciplinary team to evaluate and improve the charge capture process.  

• Review the medical record for observation cases to ensure accurate and timely billing of observation hours and appropriate charges.  

• Utilize the application of medical necessity review criteria tools (MCG and/or InterQual).  

• Work cooperatively to review, evaluate and improve the charge capture process to establish an enterprise uniform process.  

• Support development of performance improvement strategies in response to identified patterns and trends. 

Minimum qualifications for the ideal future caregiver include:  

• Three to five years of case management or utilization experience including acute med/surg, ICU and ER experience.  

Preferred qualifications for the ideal future caregiver include: 

• Bachelor of Science in Nursing (BSN) or a bachelor’s degree in a related field. 

• Licensed Registered Nurse (LPN) in the state of Ohio.  

• Professional certification as a Case Manager.  

• Expertise with InterQual and Milliman disease management ideologies.  

• In-depth familiarity with third party billing requirements and regulations and billing documentation requirements.  

• Understanding of CPT and HCPCS coding guidelines.  

• Finance experience.  

Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we’re dedicated to providing what matters most to you: https://jobs.clevelandclinic.org/benefits-2/