Clinical Review Nurse Care Manager

Children's Mercy KC • Kansas City, MO

7d • Onsite

About The Position

The Clinical Review Nurse Care Manager utilizes clinical expertise, evidence-based guidelines, insurance knowledge, business acumen, and high level of communication skills to ensure appropriate utilization of and reimbursement for resources from admission through hospital stay to discharge. Adeptly uses evidence based clinical practice guidelines to determine the appropriate level of care and the medical necessity of continued hospitalization. Secures initial payer authorization and continued stay payer authorization per contracts for medically appropriate level of care. Manages concurrent clinical denials through completion of verbal reconsideration process. Works with physicians and multidisciplinary teams to evaluate the medical plan, length of stay, avoidable days/delays and progression of care. Works collaboratively with Revenue Cycle to ensure authorizations and denials are addressed timely for clean claims submission. This position will participate in ongoing professional development activities, quality improvement, and continuing education activities. This role Improves efficiency and reduces health care costs as evidenced by decreased lengths of stay, decreased re-admissions, decreased denials, and increased patient satisfaction.
At Children’s Mercy, we are committed to ensuring that everyone feels welcomed within our walls. A successful candidate for this position will join us as we strive to create a workplace that reflects the community we serve, as well as our core values of kindness, curiosity, inclusion, team and integrity.
Additionally, it’s important to us that we remain transparent with all potential job candidates. Because we value the safety of the patients and families we serve, as well as the Children’s Mercy staff, we want to let you know that the seasonal influenza vaccine is a condition of employment for all employees in our organization. New employees must be willing to be vaccinated if found non-immune to measles, mumps, rubella (MMR) and chicken pox (varicella) and/or without evidence of tetanus, diphtheria, acellular pertussis (Tdap) vaccination since 2005. If you are selected for this position, you will be asked to supply your immunization records as proof of vaccination. If you and have any concerns about receiving these vaccines, medical and/or religious exemptions can be further discussed with Human Resources.

Requirements

• Bachelor's Degree BSN
• 3-5 years experience
• Experience as a care manager or demonstrated leadership skills in a previous role
• Licensed RN - MO, Registered Nurse Multistate License Missouri
• Licensed RN - Kansas, Registered Nurse Multistate License Kansas
• RN Compact license for all states besides KS and MO
• MO or KS Multistate License required within 90 days of hire
• Certified Case Manager (CCM) certification required within 3 years of hire OR
• Accredited Case Manager (ACM) certification required within 3 years of hire
• Refer to Nursing and Avdance Practice Provider Licensure and Certification policy for required Life Support Certifications Required Upon Hire

Nice To Haves

• CPN Certification Preferred

Responsibilities

• Evaluate appropriateness of each admission using evidence-based clinical guidelines to ensure correct bed status.
• Ensures medical appropriateness of care by facilitating timely and proper patient throughput progression; securing continued stay authorizations; continually reassessing medical necessity; and partnering with the multidisciplinary team.
• Mitigates and manages denials for patient status and continued patient stays with Attending Physician, Physician Advisor, Inpatient Nurse Care Manager, and insurance/payer.
• Collaborates with Revenue Cycle to improve financial processes and outcomes.
• Participate in ongoing professional development activities, making a meaningful contribution to quality improvement and continuing education of self and others.

Benefits

• The benefits plans at Children’s Mercy are one of many reasons we are recognized as one of the best places to work in Kansas City. Our plans are designed to meet the changing needs of our employees and their families.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level