High Risk Nurse Care Manager

Children’s Mercy; Kansas City (MO); On-site; USD 80,000 - 100,000; Full time

Job summary

Children’s Mercy seeks a High-Risk Nurse Lead to manage administrative processes related to medical necessity denials and care transitions. This role focuses on enhancing patient care efficiency and minimizing healthcare costs through effective risk management strategies. Candidates should hold a BSN and have 3-5 years of experience in care management.

Qualifications

• 3-5 years of experience in care management preferred.
• Licensed RN in MO or KS required upon hire.
• Must obtain KS or MO compact license within 60 days.

Responsibilities

• Track concurrent medical necessity denials and identify resolutions.
• Assist in monitoring long length of stay patients posing financial risks.
• Engage with Care Management for early escalation of patient concerns.

Skills

Leadership skills

Care management

Patient engagement

Education

Bachelor's Degree (BSN)

Tools

Life Support Certifications

Job description

The High-Risk Nurse Lead manages high-risk administrative processes and data related to medical necessity denials, clinical appeals, long length of stay rounds, and clinically/financially risky patients. Uses data tools and tracking to monitor the status and outcomes of denials and appeals to identify trends and opportunities for the patient population, hospital, care delivery model, care management practices, and payer contracting. Supports facilitation and tracking of long length of stay patients, including total charges, barriers to transition, and intervention plans. Monitors and tracks patients with financial/clinical risks requiring multidisciplinary action to address and resolve issues. The High-Risk Nurse Lead is an expert in the roles of Clinical Review Nurse Care Manager and Care Coordination Case Manager and provides support to the larger team in addressing and resolving role-specific concerns. This role aims to improve efficiency and reduce healthcare costs, evidenced by decreased lengths of stay, readmissions, denials, and increased patient satisfaction.

At Children’s Mercy, we are committed to ensuring everyone feels welcomed within our walls. A successful candidate will join us in creating a workplace that reflects the community we serve, aligned with our core values of kindness, curiosity, inclusion, team, and integrity.

We prioritize transparency with potential candidates. Due to our commitment to safety, the seasonal influenza vaccine is a condition of employment for all staff. New employees must be willing to be vaccinated if non-immune to measles, mumps, rubella (MMR), chickenpox (varicella), or without evidence of Tdap vaccination since 2005. Immunization records will be required upon hiring. Medical or religious exemptions can be discussed with Human Resources if concerns arise.

Responsibilities

• Track all concurrent medical necessity denials through verbal reconsideration, written appeal, and final outcome to identify and resolve insurance/payer issues, clinical care concerns, and Care Coordinator performance improvements.
• Assist management in long length of stay rounds to monitor extended stay patients posing financial risks.
• Engage with the Care Management Department and Leadership for early escalation of patients presenting with concerns related to clinical, financial, social, or payment barriers.

Qualifications

• Bachelor's Degree (BSN) and 3-5 years of experience; experience as a care manager or demonstrated leadership skills preferred.
• One of the following licenses or certifications required upon hire: Licensed RN in MO (multistate license required), Licensed RN in KS (multistate license required), American Case Management Certification or Certified Case Manager.
• Must obtain KS or MO compact license within 60 days if not already licensed.
• Employees must obtain American Case Management Certification or equivalent within 365 days; same for Certified Case Manager.
• Required Life Support Certifications as per Nursing and Advanced Practice Provider Licensure and Certification policy.

Benefits at Children's Mercy

Our benefits plans are designed to meet the changing needs of our employees and their families, contributing to our recognition as a top workplace in Kansas City.

Starting Pay

The pay range begins at $36.75/hr, with offers determined based on education and experience.

Remote Work / Work from Home

This position requires onsite work at one of our Children's Mercy locations; remote work is not permitted.

EEO Employer / Disabled / Vet

We hire based on skills, expertise, and ability to maintain professional relationships. We do not discriminate based on race, color, religion, sex, national origin, age, disability, or other protected statuses. A drug screen is required upon hire. We are smoke and tobacco-free.

Our commitment to Diversity & Inclusion

We are dedicated to creating a diverse and inclusive workforce. We believe that our strength comes from our team’s varied backgrounds, which enhances our patient care and workplace environment. We welcome contributions from individuals of all backgrounds, including education, culture, ethnicity, race, sex, sexual orientation, gender identity and expression, national origin, age, languages spoken, veteran status, and beliefs.