Senior Professional Care Manager
University of Pittsburgh Medical Center - Pittsburgh, PA

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UPMC Presbyterian offers a wide range of health care services, providing state-of-the-art medical care to patients in the tristate area and throughout the world. This 913-bed facility in Oakland is a renowned center for organ transplantation, and a recognized leader in cardiology and cardiothoracic surgery, critical care medicine, oncology, neurosurgery, and trauma services.

We are seeking candidates for a full-time senior professional care manager opportunity supporting the Collaborative Case Management Department in our Oakland location. Your responsibilities will include coordinating the clinical and financial plan for patients, and performing overall utilization management, resource management, discharge planning and post-acute care referrals and authorizations. You will work with a multi-disciplinary team in resource management, discharge planning and care facilitation.

Responsibilities:
  • Performs clinical review on admission and/or continued stay using InterQual criteria to determine appropriate level of care (Inpatient, OBS, etc.)
  • Obtains all necessary authorizations for level of care including admission and continued stay
  • Follows payer-specific requirements to obtain and document authorizations
  • Reviews medical record daily to ensure patient continues to meet LOC requirements and that chart documentation supports LOC determination
  • Works with Physician Advisor and Attending Physicians to obtain necessary documentation to support current LOC, alters LOC as needed and expedites discharge planning for patients who no longer require hospital service
  • Takes leadership role in concurrent denial process
  • Works with Care Management Director, Physician Advisor, Attending Physicians and clinical team to obtain necessary information and documentation to support LOC
  • Initiates acceptance of lower LOC when appropriate with assistance from billing office
  • Obtains Consent to Appeal on Behalf of Member on all cases with concurrent denial
  • Starts discharge planning on admission and ensures DC documentation is completed and updated regularly
  • Proactively identifies barriers to discharge and works with multi-disciplinary team to expedite care, monitor length of stay (LOS) and facilitate discharge
  • Addresses complex clinical and social situations efficiently in order to avoid unnecessary delays in discharge
  • Collaborates with patients, caregivers, internal/external healthcare providers, agencies and payers to plan and execute a safe discharge
  • Re-evaluates and revises discharge plan as patient clinical condition merits
  • Develops alternative/multiple discharge plans in anticipation of patient need for post-acute services
  • Promotes advancement of knowledge and skills of other disciplinary teams and lay members of the community by serving as a resource to internal and external individual groups
  • Serves as a leader within the care management department in completing his/her assignment
Requirements:
  • Graduate of approved school of nursing
  • 2 years of nursing experience
  • BSN or related bachelors degree
  • 2 years of care management experience
  • Knowledge of healthcare financial and payor issues
  • Knowledge of state, local, and federal programs
  • Use of InterQual criteria preferred
  • Currently licensed as professional nurse in the commonwealth of PA
  • UPMC approved care management certification preferred
UPMC also offers a variety of benefit options designed to provide personal security, convenience, and assistance to you and your family. With this flexibility and choice, you can decide which options best meet your needs.

HEALTHeCAREERS Network - 3 years ago - save job - block
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UPMC is a $10 billion global health enterprise with more than 55,000 employees headquartered in Pittsburgh, Pa., and is transforming health...