Medical Claims Review Manager jobs in Kansas City, MO

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.

The Manager of Utilization Review will provide leadership to integrated inpatient teams and assist the Director in the management of the department, including personnel development and fiscal management as well as training/oversight of programs and services. Responsible for effective utilization review and proper resource management, including patient statusing processes, ongoing monitoring of medical necessity review functions utilizing InterQual and/or MCG screening guidelines, and oversight of clinical denials/appeals. The Manager of Utilization Review participates in department and hospital performance improvement activities; is responsible for outcomes reporting; quality; and Lean process improvements; and facilitating the quarterly Utilization Review Committee meetings. Provides evidence-based and outcome-focused family centered care management and services.

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 and COVID-19 vaccines 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.

Personnel management:

Directs team members in the delivery of utilization management and care management services.
• Promotes a collaborative and high-performance work environment.
• Provides support and guidance to team members to develop problem-solving and leadership skills by providing education, training, coaching, role modeling and mentoring.
• Determines staffing standards and monitors scheduling practices based on industry and organizational productivity guidelines.
• Delegates special projects and committee appointments as needed.
• Interviews and hires job applicants in collaboration with department personnel, department director, and human resources.
• Evaluates employee performance and counsels as needed.
• Assesses employee job satisfaction, recruitment, and retention programs.
• Assists department staff in problem solving, conflict resolution, and crisis management.
• Maintains accurate personnel files in compliance with regulatory and organizational standards.
• Develops professional expertise and leadership of the Admission and Denials Care Managers, Observation/Extended Stay Care Managers, and Utilization Review Specialists, including new hire orientation, competency assessments and professional development.
• Partners with Revenue Cycle, Payor Relations, HIM and Risk Management in support of utilization management and high-risk patients.
• Creates accountability and escalation pathways for resolving utilization management issues throughout the health system.
• Acts as liaison to facilitate communication and collaboration between all care partners (internal and external partners, etc.)
• Establishes relationships with payors to promote continuum of care alignment and strategies.
• Facilitates development of trusting relationships and partnerships with physicians, nursing, payers, patients, and coworkers.

Participates in department and organization performance improvement activities:

• Participates on CQPI and Lean project teams within the department and organization; completes project assignments on time.
• Implements a Quality Improvement Plan that identifies ways to improve department performance and clinical practice.
• Utilizes appropriate resources to organize/analyze QI/research data and interpret/disseminate findings.
• Develops and analyzes reports of key metrics for both staff performance, as well as clinical trends within the delivery system.
• Identifies trends or risk management issues.
• Creates an atmosphere where performance improvement is fully integrated as a part of daily operations.
• Assists the director in the implementation of lean principles and change management principles throughout the department.
• Collaborates closely with other leaders within Revenue Cycle to impact overall performance improvement.

Department management and program development:

• Models and creates an environment aligned with Children's Mercy Guiding Behaviors.
• Collaborates with department leadership to implement and monitor a long-range strategic plan/departmental goals and objectives.
• Coordinates and integrates interdepartmental and intradepartmental services.
• Participates in the development and/or revision of department/unit standards of care/practice.
• Maintains knowledge and development of computer/telephone hardware and software.
• Acts as a liaison/expert regarding utilization review, care management, and care continuum services to internal stakeholders and external programs, services and provider groups as requested.
• Maintains relationships with payors and key stakeholders to keep informed of policies and procedures.
• Communicates with external payors and third parties, as needed, to resolve issues or communicate specific information about the department or specific cases.
• Maintains current knowledge of changing regulatory requirements, legislation, accreditation, technology, and standards of care/practice impacting care management.
• Develops and revises utilization review and care management protocols, and standards of care/practice.
• Attends department and hospital meetings appropriate for area of responsibility and assigned committees.
• Actively participates and provides leadership for education programs, department meetings and assigned committees; Communicates pertinent information.
• Actively collaborates internally with payer relations, PFS, PCN, and others.
• Interacts with executive leadership to facilitate quality based, cost effective, patient statusing in the most appropriate setting and in compliance with regulatory and revenue cycle requirements related to utilization review.
• Engages in the utilization review committee.

Assists the department Director with fiscal management and accountability:

• Utilizes financial data to evaluate existing programs and to formulate a business plan to develop new programs/services.
• Performs, monitors, and manages root cause analysis of authorization denials to ensure improvement and optimum reimbursement.
• Maintains knowledge of legislative and regulatory activities that impact reimbursement for clinical services and professional activities.
• Demonstrates prudent resource utilization.
• Educates personnel on the fundamentals of healthcare economics.
• Performs department audits to ensure regulatory and department standards and guidelines are maintained by staff.

Educational Requirements/Licensure:

• Bachelor's Degree in Nursing (BSN) plus 3-5 years' experience, including Utilization Review (plus licensure below) OR
• Master's Degree in Nursing plus 1-2 years' experience, including Utilization Review (plus licensure below).
  • Note: A Master's Degree, in Nursing, is required within 4 years of hire
• One of the following: Licensed RN - MO, Registered Nurse Multistate License Missouri required upon hire. RNs who reside in Missouri hold a Missouri Multi-State (Compact) License If RN and Required Upon Hire
• One of the following: Licensed RN - Kansas, Registered Nurse Multistate License Kansas required upon hire. RNs who reside in Kansas hold a Kansas Multi-State (Compact) License If RN and Required Upon Hire
• One of the following: RN Compact license for all states besides KS and MO
• Refer to Nursing and Advanced Practice Provider Licensure and Certification policy for required Life Support Certifications, required upon hire

Certifications:

• One of the following preferred, required within 2 years of employment: American Case Management OR Certified Case Manager, or equivalent

Our pay ranges are market competitive. The pay range for this job begins at $41.26/hr, but your offer will be determined based on your education and experience.

This position is not eligible work remotely, which means that the person hired will be required to work onsite at one of our Children's Mercy locations and may not work from home.

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.

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.