Clinical Financial Case Mgr

Scope of Position

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 positions requires that the individual be able to identify trends and offers suggestions for process improvement to support avoidance of and recoupment of lost revenue.

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 ICD
10 and CPT4 coding are performed on each claim. Responsible for identifying trends in denials and providing education to clinical staff and managed care payers to reduce these denials;
Gather all clinical and supporting evidence and submit to payers for pre-determination of off‑label services and/or complex procedures and treatment modalities;
Communicate status of pre-determination request to stakeholders;
Educate clinical and other staff on off‑label definitions and policies and requirements for authorization on other complex cancer treatment modalities;
Provide clinical support to non-clinical pre‑certification staff as needed. Must have a strong understanding of the disease implications, use of various treatment modalities, and expected outcomes.

• 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.