Clinical Finance Case Management Specialist

Position: Clinical Finance Case Management Specialist 2

Responsibilities

• Use of clinical knowledge for the management of complex James Cancer Center ambulatory medical necessity denials through the appeals process.
• Providing scientific evidence to support cutting edge therapies, and diagnostic services.
• Providing clinical education to payers regarding current standard of care treatment and other frequently denied services as applicable.
• Identifying trends, and areas for needed clinical education, to decrease denials where applicable.
• Submission of pre-determination requests proactively supporting clinicians in efforts to identify areas where loss of revenue is at risk to mitigate that risk.
• Provide support to the CBO Medicare billing area in the form of correcting billing errors before the bill is sent to the payer.
• Provide clinical support for the review of clinical data to access current policies and processes impacting revenue.
• Provide coverage support to the pre-certification area when clinical intervention is required.

Requirements

• Associate Degree in Nursing: preferred.
• Minimum of 3 years oncology experience: preferred.
• 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 preferred.
• Strong knowledge of: ICD-9-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.

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