Position Summary

Responsible for daily operational management of Revenue Cycle Clinical Support Staff primarily involving the oversite of Clinical Pre-Certification Peer to Peer Clinical Appeals Denial Analysis and Prevention for The Ohio State University Health System.Implements and supports the philosophy mission values standards policies and procedures of The Ohio State University Wexner Medical Center. Functions within multidisciplinary teams leading staff to secure complex pre-authorizations and 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. Makes determinations on the appropriate level of care (Inpatient or Observation) based on the ability to read understand and interpret documented clinical information. Is a Subject Matter Experts (SME) for commercial and governmental payer requirements and audits such as RAC MAC QIO etc. Maintains an awareness of State and National Health care trends JCAHO CMS and third-party payer Utilization Management guidelines. Manages escalation processes to administration regarding the need to cancel or reschedule elective surgery when authorization is not secured along with escalations to Managed Care on payer denials.

Is a SME and leads team members in understanding critical components 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 understand how to secure authorizations and appeal/prevent denials. Guides staff on how to read understand and interpret a payer remit denial/remark codes and expected reimbursement to determine the cost effectiveness of completing an appeal. Is versatile flexible and very adaptable to change because the payer rules change constantly.Troubleshoots problem solves continuously learns is highly independent self-motivated and has an elevated level of interpretive skills with the ability to work closely with departments such as Legal Medical Information Management Physician groups and the Business Office. Develops and implements policies procedures workflows and auditing procedures. Serves as a resource on governmental regulatory interpretation. Significant involvement with physicians physician leaders and administrators.

Scope of Position

Revenue Cycle Clinical Support Office (RCCS) is an area within Access and Revenue Cycle Management Shared Services responsible for Clinical Pre-Certification Case Reviews Pre-billing edits 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. RCCS is integral to the Revenue Cycle and supports cash collection through preventing and appealing denials.

• Bachelors degree in nursing with current license required.
  • Minimum of 5 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.