Job Description

Job Title: Professional Care Manager (RN)
Job ID: 687644
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Presbyterian
Department: SPF-Value Plan
Location: 200 Lothrop Street, Pittsburgh PA 15213

Description

In this position, the Care Manager starts Telemedicine discharge planning upon referral and ensures DC documentation is completed and updated regularly.  The Care Manager will proactively identify barriers to discharge and work with a multi-disciplinary team to expedite care, monitor length of stay (LOS) and facilitate telemedicine discharge. 

The Care Manager will process and coordinate home intravenous antibiotic referrals through an innovative, multidisciplinary, collaborative approach utilizing Telemedicine services. Conduct comprehensive face to face assessment, education, coordination, and follow-up to ensure a seamless transition to home for those discharged on intravenous antibiotic therapy. Review UPMC Health Plan data and documentation in the member electronic health records as appropriate and identify barriers to care compliance based on clinical standards with a goal of reducing readmission frequency, promoting care independence, and reducing cost.


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.
  • 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 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 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.  
  • Minimum 2 years of acute care 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.
  • UPMC Corporate Care Management Training Certificate of Completion required with 4-6 weeks of hire.
  • UPMC approved Care Management certification preferred
  • Act 34 Criminal Clearance
  • Registered Nurse

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

Salary Range: $26.64 to $44.88

Union Position: No

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