Job Description

Job Title: Professional Care Manager (RN) - Hematology Oncology/Bone Marrow Transplant
Job ID: 695157
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: Children's Hospital of Pgh
Department: Hematology Oncology Admin
Location: 4401 Penn Avenue, Pittsburgh PA 15224

Description

Are you an experienced oncology nurse or pediatric nurse with an eagerness to learn? Are you ready to take the next step in your nursing career? Children's Hospital of Pittsburgh of UPMC is searching for a full-time Professional Care Manager to manage prior authorizations required for chemotherapy and bone marrow transplants. 

This position will work daylight hours, Monday - Friday

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 
  • Two (2) years of nursing experience required
  • Pediatric nursing experience preferred
  • 3 years experience with prior authorization strongly preferred
  • Oncology and/or bone marrow transplant experience strongly preferred
  • BSN or related Bachelors degree strongly preferred
  • Must be flexible and a team player
  • 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 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: $26.64 to $44.88

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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