Provides advanced clinical appeal services with a focused responsibility for review and escalation of complex patient account denials.
Independently performs complex clinical reviews and evaluates relevant payer contractual terms and payer policies/guidelines to determine need for and method of escalation.
Monitors and reports on commercial and governmental payer denial trends and assists in the development of denial prevention strategies.
Assists the Manager as clinical and operational resource for the clinical appeals team, supporting complex case resolution, payer policy interpretation, regulatory compliance, and technology-enabled workflows.
Monitors payer and regulatory updates, disseminating this information with the team.
Assists the Manager in evaluating workflows for effectiveness, and in supporting the adoption of new tools and systems.
Oversees quality of clinical appeals and provides actionable quality assurance insights to management.
Assists the Manager in monitoring productivity and performance trends.
Aligns team operations with departmental goals, payer requirements, financial performance, and organizational technology initiatives through collaboration, coaching, and process improvement.

Medical, dental and vision coverage, with Ohio State paying a significant portion of the cost.
Paid time off, including sick and vacation time and 11 holidays.
State retirement plan or an alternative retirement plan, both with generous employer contributions.

Clinical Financial Case Manager – RN, Escalation Lead

Key skills