Clinical Financial Case Manager RN

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Job Title:

Clinical Financial Case Manager RN

Department:

Health System Shared Services | Revenue Cycle Clinical Support

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, internal and external escalations, and denial management. RCCS is integral to the Revenue Cycle and supports cash collection through preventing and appealing denials.

Position Summary

The Clinical Financial Case Manager, RN – Escalation Lead provides advanced clinical appeal services with a focused responsibility for review and escalation of complex patient account denials. This role independently performs complex clinical reviews and evaluates relevant payer contractual terms and payer policies/guidelines to determine need for and method of escalation. The Lead will monitor and report on commercial and governmental payer denial trends and assist in the development of denial prevention strategies, while maintaining a caseload of standard appeals as needed.

In a leadership capacity, the Lead 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. The Lead monitors payer and regulatory updates, disseminating this information with the team. The Lead assists the Manager in evaluating workflows for effectiveness, and in supporting the adoption of new tools and systems.

The position assists the Manager in overseeing quality of clinical appeals and provides actionable quality assurance insights to management. The Lead also assists the Manager in monitoring productivity and performance trends. Through collaboration, coaching, and process improvement, the Lead aligns team operations with departmental goals, payer requirements, financial performance, and organizational technology initiatives.

Minimum Qualifications

For Hire:

• Bachelor’s Degree in Nursing (BSN) from an accredited nursing program.
• Current, unrestricted Registered Nurse (RN) license in the applicable state of practice.
• Minimum of 2 years of experience in claim denial escalation processes.
• Minimum of five (5) years of experience in clinical appeals.
• Minimum of five (5) years of relevant professional nursing experience, which may include utilization review, case management, prior authorization, precertification, care coordination, or related clinical revenue cycle functions.
• Demonstrated working knowledge of medical necessity criteria, MCG/InterQual criteria, and governmental and commercial payer requirements.
• Ability to independently review and interpret medical records, clinical documentation, and diagnostic testing to support quality assurance and payer compliance.
• Proficiency in medical terminology and foundational knowledge of ICD-10 diagnosis coding and CPT/HCPCS procedural coding.
• Experience using electronic health records (EHRs), payer portals, and clinical or revenue cycle technology platforms.
• Effective written and verbal communication skills, including the ability to present QA findings and performance insights to leadership.

Equivalency Statement:

An equivalent combination of education, licensure, and relevant experience may be considered in accordance with organizational HR policy.

Preferred:

• Advanced Degree.
• Five (5) or more years of experience in claim denial escalation processes.
• Prior experience in a lead, mentor, or informal supervisory capacity, including workflow coordination, staff education, onboarding, QA support, or performance coaching.
• Advanced knowledge of payer policies, medical necessity guidelines, levels of care determination, and regulatory compliance requirements.
• Experience supporting quality assurance activities, audits, denial management, data analysis, and process improvement initiatives.
• Demonstrated ability to analyze operational and quality metrics, identify trends, and translate data into actionable recommendations for management.
• Experience participating in or supporting implementation of new technologies, automation tools, analytics platforms, or system enhancements.
• Strong facilitation and presentation skills, including experience educating clinical and non-clinical staff.
• Professional certification related to case management, utilization review, or healthcare quality (e.g., CCM, ACM, CPUR) preferred.

Additional Information:

Location:

Remote Location

Position Type:

Regular

Scheduled Hours:

40

Shift:

First Shift

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The university is an equal opportunity employer, including veterans and disability.