Thanks for your interest in Children's Mercy!

Do you envision finding a meaningful role with an inclusive and compassionate team? At Children’s Mercy, we believe in making a difference in the lives of all children and shining a light of hope to the patients and families we serve. Our employees make the difference, which is why we have been recognized by U.S. News & World Report as a top pediatric hospital, for eleven consecutive years.

Children’s Mercy is in the heart of Kansas City – a metro abounding in cultural experiences, vibrant communities and thriving businesses. This is where our patients and families live, work and play. This is a community that has embraced our hospital and we strive to say thanks by giving back. As a leader in children’s health, we engage in meaningful programs and partnerships throughout the region so that we can improve the lives of children beyond the walls of our hospital.

Overview

The BSN, Admission and Denials Care Manager utilizes clinical expertise, insurance knowledge, business know-how, and high level of communication to ensure appropriate utilization of resources at time of patient admission and manages clinical denials received by the Care Management Department. The goal of the Admission and Denials Care Manager is to work alongside admitting physicians and house shift supervisors by using clinical guidelines to ensure appropriate bed status. This position will oversee all denials by coordinating physician peer-to-peers, communication with external payers, and seeking all appeal options feasible to reduce risk of revenue loss to the organization. This position will participate in ongoing professional development activities, quality improvement, and continuing education activities.

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 theseasonal influenzaandCOVID-19vaccines are 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 become a finalist for this position, and have any concerns about receiving these vaccines, medical and/or religious exemptions can be further discussed with Human Resources.

Responsibilities

Facilitate timely and proper patient throughput progression, centered around interdisciplinary communication:

• Collaborates with all members of the interdisciplinary team to facilitate the care coordination and care delivery for the purpose of facilitated patient flow through the system. This includes Patient Access, House Supervisor, Inpatient Care Managers, Nursing, Registration, Patient Financial Services, and Revenue Cycle.

• Foster trust and confidence among the interdisciplinary team related to admission guideline decision.

• Engage with physician leaders to provide education and promote optimal patient care.

• Coordinates the patient plan of care with the inpatient care manager to ensure all critical elements have been communicated.

• Communicate all elements of the recommended admission plan to key stakeholders and establishes a target length of stay (LOS) and potential discharge disposition for all patients.

  Evaluate appropriateness of each admission using evidence-based clinical guidelines to ensure correct bed status:

• Coordinate with Care Teams/Social Work to facilitate alternate care settings when appropriate or identifies patients for whom standard of care treatments could be safely rendered at home to prevent non-medically necessary admissions.

• To accomplish the goals of utilization management, the bed status must be correct from the time of admission, leading to proper resource utilization, care, and management of the patient.

• Ensure admission documentation meets clinical condition through coordination with physician and care teams. Support improving provider documentation to reflect the level of services rendered.

• Provide early identification of high-risk patients and needs.

• Advocacy of evidence-based clinical guidelines to validate treatment plan aligns with bed status.

• Understand local, state, and federal regulations, while adherence to organizational policies, rules, and regulations.

• Efficiency and decreased health care costs are evidenced by decreased lengths of stay, decreased readmissions, decreased denials, and increased patient satisfaction.

• Demonstrates ability for complex clinical decision making. Critically evaluates and analyzes physical and psychosocial assessment data and differentiates between normal and abnormal clinical findings.

  Performs denial and appeal management processes to attempt securement of reimbursement for services rendered at the appropriate level of care:

• Provide evidence-based clinical guideline and supporting clinical information to support successful appeals of all denials.

• Coordinate overall appeal process and maintain appropriate follow-up on appealed claims within expected timelines, including but not limited to coordination of physician peer-to-peer and appeal letters.

• Continuous review and follow-up of outstanding denials and appeal to exhaust all appeal options leading to overturned denials and preventing upheld denials.

  Participate in ongoing professional development activities, making a meaningful contribution to quality improvement and continuing education of self and others:

• Assumes leadership role in the clinical setting.

• Provides clinical consultation to physicians and Children’s Mercy staff regarding coordination of care, case management, and the continuum of care issues in a timely, positive manner.

• Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate timely discharges.

• Refers appropriate patients to Social Work for psychosocial intervention, guardianship, financial, resource management and complex discharge planning in a timely manner.

• Demonstrate responsibility, efficiency, good organizational skills, and effective communication skills with internal and external customers.

• Responds to all requests appropriately, accurately, and in a timely manner.

• Understand local, state, and federal regulations, while adherence to organizational policies, rules, and regulations.

• Actively engage in the Children’s Mercy Lean System including participation in huddles, problem-solving methodology, and submission of data as requested.

• Regularly attends and contributes to the success of department meetings, committees, and other CM committee assignments.

• Provides clinical consultation to physicians and Children’s Mercy staff regarding coordination of care, case management, and the continuum of care issues.

• Participates in quality improvement, hospital committees, and/or educational activities within and outside the immediate department.

• Maintains availability for peer consultation and communicates with staff in a timely, effective manner.

• Represents the care management team within the hospital and community to facilitate collaboration.

• Acts as preceptor and mentor to new employees, students, and allied health professionals in the department.

• Assist in the department as requested, shows flexibility in changes in work assignment.

Qualifications

Bachelor's Degree (BSN) and 3-5 years' clinical experience. Previous experience as a Care Manager or demonstrated leadership skills in a previous role.

One of the following:

• Licensed RN - MO, Registered Nurse Multistate License Missouri required upon hire

• Licensed RN - Kansas, Registered Nurse Multistate License Kansas required upon hire

• Certified Case Manager, American Case Management required upon hire

• RN Compact license for all states besides KS and MO

Employees must obtain Certified Case Manager (CCM), or equivalent, within 3 yrs

Employees must obtain American Case Management (ACM), or equivalent, within 3 yrs

CPN Certification Preferred

Benefits at Children's Mercy

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.

Learn more about Children’s Mercy benefits. (https://www.childrensmercy.org/careers/why-childrens-mercy/employee-benefits/)

Starting Pay

Our pay ranges are market competitive. The pay range for this job begins at $33.95/hr, but your Salaried offer will be determined based upon your education and experience.

Remote Work/Work from Home

This is an intermittent remote position, which means that the person hired will work with his or her manager to determine a schedule that includes both at home and on-site hours at a Children’s Mercy location. The incumbent must live in the Kansas City metro area.

EEO Employer/Disabled/Vet

Children’s Mercy hires individuals based on their job skills, expertise and ability to maintain professional relationships with fellow employees, patients, parents and visitors. A personal interview, formal education and training, previous work experience, references and a criminal background investigation all are factors used to select the best candidates. The hospital does not discriminate against prospective or current employees based on the race, color, religion, sex, national origin, age, disability, creed, genetic information, sexual orientation, gender identity or expression, ancestry or veteran status. A drug screen will be performed upon hire. Children’s Mercy is smoke and tobacco free.

Our commitment to Diversity & Inclusion

CM is committed to creating a diverse and inclusive workforce. Our patients and families come from all walks of life, and so do we. We know that our greatest strengths come from the people who make up our team so we hire great people from a wide variety of backgrounds, not just because it’s the right thing to do, but because it makes our hospital stronger and our patient care more compassionate.

If you share our values and our enthusiasm for service, you will find a home at CM. In recruiting for our team, we welcome the unique contributions that you can bring, including education, ideas, culture, ethnicity, race, sex, sexual orientation, gender identity and expression, national origin, age, languages spoken, veteran status, color, religion, disability and beliefs.

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Requisition ID2024-29695

Requisition Post Information* : Posted Date2 weeks ago(6/6/2024 3:13 PM)

Posting CategoryNursing

DivisionCARE MANAGEMENT

Work TypeFull Time

Work DaysTBD

Work Hours0700-1900

FLSA StatusExempt

Location : NameAdele Hall

Recruiter : Full Name: First LastTerry Worthington-Brown

Recruiter : Emailtlworthingtonbro@cmh.edu