This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Clinical Financial Case Manager RN in United States.
This role is a key clinical and financial liaison within a high-impact revenue cycle environment, focused on reducing denials and improving reimbursement outcomes through expert-level clinical review and escalation.
You will evaluate complex inpatient and outpatient cases, interpret payer policies, and determine the appropriate clinical justification for appeals and escalations.
Working in a remote setting, you will collaborate closely with clinical, revenue cycle, and payer relations teams to resolve high-complexity denial cases.
The position also plays a strategic role in identifying denial trends and supporting prevention initiatives that improve organizational financial performance.
In addition to casework, you will contribute to leadership activities by supporting workflow optimization, quality assurance, and team coaching.
This is a highly analytical and detail-driven role requiring strong clinical judgment, regulatory knowledge, and the ability to influence outcomes across multiple stakeholders.
Accountabilities:
- Independently review and manage complex clinical denial cases, determining medical necessity and appropriate escalation pathways based on clinical documentation and payer policies.
- Conduct advanced clinical appeals, interpreting payer contracts, guidelines (MCG/InterQual), and regulatory requirements to support reimbursement outcomes.
- Monitor, analyze, and report on denial trends across commercial and governmental payers to support prevention strategies.
- Assist leadership in quality assurance activities, workflow evaluation, and performance monitoring within the clinical appeals function.
- Support team coordination by acting as a clinical resource, providing guidance on complex cases, and assisting with coaching and knowledge sharing.
- Collaborate with cross-functional teams to improve denial management processes, technology adoption, and operational efficiency.
- Stay current on payer policy changes and regulatory updates, ensuring timely dissemination and application within clinical workflows.
Requirements:
- Bachelor’s Degree in Nursing (BSN) and active, unrestricted Registered Nurse (RN) license in the applicable state.
- Minimum 5 years of clinical nursing experience, including utilization review, case management, prior authorization, or related revenue cycle functions.
- At least 2 years of experience specifically in claim denial escalation and advanced clinical appeals.
- Strong knowledge of medical necessity criteria (MCG/InterQual), payer guidelines, and healthcare reimbursement processes.
- Ability to independently review and interpret clinical records, diagnostic data, and documentation to support appeal decisions.
- Familiarity with ICD-10, CPT/HCPCS coding concepts, and healthcare compliance standards.
- Experience working with EHR systems, payer portals, and revenue cycle technologies.
- Strong analytical, communication, and presentation skills with the ability to report findings to leadership.
- Preferred: advanced degree, leadership or mentoring experience, certifications such as CCM/ACM/CPUR, and exposure to process improvement, audits, or healthcare technology implementation.
Benefits:
- Fully remote work arrangement with standard full-time schedule (40 hours/week, first shift).
- Comprehensive healthcare coverage including medical, dental, and vision plans.
- Generous paid time off, including vacation, sick leave, and 11 paid holidays.
- Retirement plan options with employer contributions.
- Opportunity to work within a leading academic health system environment focused on innovation and care excellence.
- Access to strong professional development opportunities and exposure to advanced clinical revenue cycle operations.
- Stable employment structure with eligibility for additional organizational benefits and wellness support programs.
How Jobgether works:
We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.
We appreciate your interest and wish you the best!
Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.
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