Clinical Case Manager

Job Title: Clinical Financial Case Manager

Department: James | Pharmacy Administration

Scope of Position

The Senior Reimbursement Analyst position is responsible for intervention and follow-up on accounts that require clinical interpretation and analysis along the revenue cycle. Primary focus will be assuring precertification for outpatient procedures and accounts that are rejected from the payers for a variety of reasons. This position requires a high level of clinical knowledge and the ability to use a work proficiently in the Integrated Health Information Systems (IHIS). In addition, this position provides support through education and communication to other departments such as MIM, PCRMs, Physicians, Nurse Practitioners, PAs, and other clinical personnel. This position requires the individual to identify trends and offer suggestions for process improvement to support avoidance of and recoupment of lost revenue.

Position Summary

Responsible for follow-up on rejected and denied claims using evidence‑based support and other documentation as needed. Works with Medical Information Management to ensure proper ICD10 and CPT4 coding are performed on each claim. Identifies trends in denials and provides education to clinical staff and managed care payers to reduce these denials; gathers all clinical and supporting evidence and submits to payers for pre‑determination of off‑label services and/or complex procedures and treatment modalities; communicates status of pre‑determination request to stakeholders; educates clinical and other staff on off‑label definitions and policies and requirements for authorization on other complex cancer treatment modalities; provides clinical support to non‑clinical pre‑certification staff as needed. Must have a strong understanding of disease implications, use of various treatment modalities, and expected outcomes.

Minimum Qualifications

• Associate or Bachelor Degree in Nursing preferred.
• Minimum of 3 years oncology experience expected.
• Experience with Windows, Excel, Access, and intranet/internet navigation tools.
• Minimum of 3 years experience in the field of oncology with solid clinical skills and current clinical practices required.
• Experience in physician practice and/or utilization review a plus.
• Knowledge of Medicare and commercial insurance reimbursement expected.
• Strong knowledge of ICD‑10‑CM, HCPCs, and CPT coding preferred.
• Excellent verbal and written skills required.
• Proficient in the use of computer‑based research and medical record documentation required.
• Use of computer‑based billing systems and databases a plus.

Location: Ackerman Rd, 660 (0242)

Position Type: Regular

Scheduled Hours: 40

Shift: First Shift

Final candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post‑offer process.

The university is an equal‑opportunity employer, including veterans and disability. As required by Ohio Revised Code section 3345.0216, Ohio State will educate students by means of free, open, and rigorous intellectual inquiry to seek the truth; equip students with the opportunity to develop intellectual skills to reach their own, informed conclusions; not require, favor, disfavor or prohibit speech or lawful assembly; create a community dedicated to an ethic of civil and free inquiry, which respects the autonomy of each member, supports individual capacities for growth and tolerates differences in opinion; treat all faculty, staff and students as individuals, hold them to equal standards and provide equality of opportunity with regard to race, ethnicity, religion, sex, sexual orientation, gender identity or gender expression.