FINANCE CASE MANAGER

Cleveland Clinic Indian River Hospital - Vero Beach, FL

Full-time - Mid Level

Vero Beach, FL

501-1,000 employees

Hospitals

About the position

The Finance Case Manager plays a crucial role in supporting the revenue cycle by conducting retrospective reviews to ensure compliance with medical necessity criteria. This position is responsible for managing payer denials and appeals, conducting audits, and improving charge capture processes. The role requires collaboration with various departments to enhance reimbursement strategies and ensure adherence to regulatory requirements. The position allows for remote work from specific states, including Florida, Ohio, and Nevada.

Responsibilities

• Supports the denial and appeal process within the Payer Denial Management department.
• Coordinates denial appeal follow-up and analyzes provided clinical documentation.
• Completes review of the medical record and formulates the appeal letter.
• Participates in the application of medical necessity review and utilizes criteria tools (MCG and/or InterQual).
• Ensures compliance standards are met with required elements and provides feedback to the management team.
• Relays documentation improvement opportunities to assist with appeal defense process.
• Conducts audit reviews to assure activities conform to regulatory requirements.
• Supports the development of performance improvement strategies in response to identified patterns and trends involving government payers.
• Works with a multi-disciplinary team to evaluate and improve the charge capture process.
• Reviews the medical record for Observation cases to ensure accurate and timely billing.

Requirements

• Bachelor of Science in Nursing or Bachelor's degree in a related field preferred.
• Licensed Registered Nurse (RN) in the state of Florida.
• Minimum 3-5 years Care Management or Utilization experience, including acute med/surg experience required.
• Expertise with InterQual and Milliman disease management ideologies preferred.
• In-depth familiarity with third party billing requirements and regulations preferred.
• Understanding of CPT and HCPCS coding guidelines preferred.

Nice-to-haves

• Professional certification as a Case Manager preferred.
• Expertise with InterQual and Milliman disease management ideologies preferred.

Benefits

• Remote work options from Florida, Ohio, or Nevada.