Job Description

Job Title: Professional Care Manager (RN)
Job ID: 680290
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC St. Margaret
Department: Care Management
Location: 815 Freeport Road, Pittsburgh PA 15215

Description

Are you interested in an opportunity to work as a nurse care manager for one of Greater Pittsburgh's Magnet Recognized hospitals? UPMC St. Margaret is hiring a Full-Time Professional Care Manager to help support the Case Management Department for its Aspinwall location. This position will work standard daylight hours.

**Nurses with 2 years of nursing experience may be considered for this position. The title and salary range of the position may vary depending on education level and any years of relevant case management background. Salary range as posted is for Sr. level Care Manager.**

Healing is just one aspect of a hospital stay. For patients and their families, there are many clinical opinions, specialist referrals, treatment choices, and financial considerations at play--navigating all of that can be a confusing and overwhelming process. They need an advocate, someone who foresees their needs, knows their options, and begins strategizing their way home from the moment of admission.

An essential member of the care delivery team, you will apply your own judgment and problem-solving skills to ensure each patient is provided with efficient, quality care while minimizing risks, delays, and unnecessary costs. You will work hand-in-hand with the multidisciplinary team as well as internal and external providers and agencies to execute a safe discharge and a clear path forward for patients and their families, including plans for self-management, at-home care, and post-acute referrals and outreach, as needed.

The Professional Care Manager is a valued step in the UPMC nursing career ladder, with opportunities for continued growth and upward advancement.

Responsibilities:
  • Attends Department meetings and Corporate Care Management Training sessions in order to maintain current knowledge of all payer and regulatory requirements, UPMC CM policies and procedures, community resources. Ensures compliance with all payer and government regulations.
  • 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. Uses InterQual criteria to justify appropriate LOC (Skilled, Rehab, Home Care, DME, etc.) and obtain all necessary payer authorizations for post-acute care. Documents Freedom of Choice re: post-acute services.
  • Evaluated issues, trends and recommends improvement to Care Manger Manager/Director and/or multi-disciplinary team.
  • 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.
  • 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.
  • Promotes patient safety. Supports CORE measures information for JCAHO requirements.
  • 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 services.
  • Serves as a leader within the care management department in completing his/her assignment.
  • Serves as a role model of excellent customer service and patient care.
  • Serves as resource to clinical and finance teams for clinical documentation requirements, level of care, insurance coverage issues, specific payer and government policies and post-acute services coverage and availability.
  • 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. Documents all Avoidable Days in CANOPY system.
  • 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.

Qualifications

  • Graduate of approved school of nursing
  • Two (2) years of nursing experience required 
  • BSN or related Bachelors degree strongly preferred
  • Previous case management experience preferred
  • Knowledge of healthcare financial and payor issues preferred
  • Knowledge of state, local, and federal programs preferred
  • Use of InterQual criteria preferred.

Licensure, Certifications, and Clearances:
  • Currently licensed as professional nurse in the Commonwealth of PA
  • CPR required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire
  • UPMC approved Care Management certification preferred
  • Act 33 Child Clearance with Renewal
  • Act 34 Criminal Clearance with Renewal
  • Act 73 FBI Clearance
  • Registered Nurse

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $28.10 to $46.35

Union Position: No

At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!

QUALITY & SAFETY
DIGNITY & RESPECT
CARING & LISTENING
RESPONSIBILITY & INTEGRITY
EXCELLENCE & INNOVATION

UPMC provides a total rewards package that can help you achieve the goals you have for your career and your personal life. Whether you want to learn a new skill through a training course, reach personal health and wellness targets, become more involved in your community, or follow a career path that provides you with the right experience to be successful, UPMC can help you get to where you want to be.



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