Care Manager-Audit/Appeals -Medical Center (8a-5p)

 
Position: Care Manager-Audit/Appeals -Medical Center (8a-5p)

Job ID: 144067

Location: US-TX-Houston

Department: Care Management

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a-5p

About Texas Children's Hospital

Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S.News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years. Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Center for pediatric research; Texas Children’s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children’s Hospital West Campus, a community hospital in suburban West Houston; and Texas Children’s Hospital The Woodlands, a second community hospital opening in 2017. We have also created the nation’s first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children’s Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation. To join our community of 13,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.

Summary:

We are searching for a Care Manager for Audit/Appeals – someone who works well in a fast-paced setting. In this position, you’ll be primarily accountable for managing the insurance defense audit process for inpatient account audits and/or the appeal process for inpatient clinical denials. You will also be responsible for coordinating response to a payer's intent to deny requested reimbursement and for identifying process improvements to avoid denials and/or audit inpatient accounts for potential recoupment and for identifying process improvements to improve revenue capture.  Lastly, you will be responsible for maintaining the ability to function as a member of the interdisciplinary healthcare team as a Care Manager through CM Certification.

 

Think you’ve got what it takes?



Responsibilities :

  • Completes a comprehensive problem identification analysis to identify opportunities for intervention and/or ensure timely evaluation and response to denials received
  • Coordinates responses for insurance defense audits received and/or appeals of all clinical denials received
  • Collaboration with internal and external customers
  • Effectively and efficiently oversees the audit process to optimally assure clinical and financial outcomes
  • Within the nursing scope of practice, the care manager auditor professional continuously assesses self-knowledge and competencies to assure job performance
  • Maintains responsibility for the assessment, coordination, and education regarding options for care and available resources
  • Coordinates, facilitates and monitors the plan of care for patients throughout the episode and continuum of care to achieve the optimal clinical and financial outcomes
  • Oversees discharge planning and facilitates safe transitions to community settings


Qualifications:

  • 5 years of Nursing experience as a Registered nurse in an acute care setting
  • An Associate’s degree in nursing
  • Preferred: A Bachelor’s Degree in Science of Nursing 
  • Knowledge of specific nursing processes, anatomy and physiology
  • Current reimbursement models: Commercial, Managed Care, Medicare & Medicaid
  • Clinical knowledge of evidence-based clinical practice, clinical trajectories and recovery patterns
  • RN - Lic-Registered Nurses from the State of Texas
  • Preferred: CASE MGM - Case Management
  • One of the following:
  1. ACM - Cert-Accredited Case Manager from American Case Management Association
  2. CCM - Cert-Certified Case Manager from Commission for Case Managers
  3. CRN-C - Cert-RN-Coder from American Association of Clinical Coders


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