Description
UPMC Health Plan is hiring a full-time Health Manager. This role will work in a hybrid structure spending approximately 50% of the time in the community in the Northwest PA region. When not travelling this role will work from home.
Preferred candidates will have previous OB/Maternity and homecare experience.
The Health Manager ensures continuity and coordination of care for Health Plan members with chronic conditions and complex health needs.
Responsibilities:
- Provides members, providers, and other stakeholders with information concerning benefits and coverage, and provides accurate information to members and families.
- Monitors and evaluates effectiveness and outcome of treatment plans, restructures as necessary to provide optimal clinically appropriate services with a goal of maintenance in the community at the least restrictive level of care and maximal use of community supports and resources.
- Works with Member Services, Network Management and Quality Management staff to assure that systematic revisions to improve services are developed and implemented.
- Utilizes supervision by identifying and reporting to supervisor clinical, utilization and outcomes issues.
- Preserve confidentiality of the member.
- Develop and coordinate an individualized treatment plan with the member, member's family, and providers.
- Evaluate the effectiveness of the treatment plan and identify gaps in service. Make recommendations for changes when indicated.
- Assist in the development and review of training materials for staff, other UPMC Health Plan departments, and network providers.
- Independent problem solving based on sophisticated knowledge of in-plan services, the provider network, member services policies, members' rights and responsibilities, and the operating practices of the organization.
- Follow-up with the member according to established timeframes to monitor their care to assess whether quality care is being provided in an appropriate setting.
- Perform duties and responsibilities in accordance with the philosophy and standards of UPMC Health Plan, including conveying courtesy, respect, enthusiasm, and a positive attitude through contacts with staff, health plan members, peers, and external contacts.
- Identifies provider issues and recommendations for improvement.
- Contact potential case management members to determine if there is a need for case management intervention.
- Receives and responds to complex calls regarding requests for services or resolution of complex issues.
- Ability to propose and implement creative solutions to member problems and to achieve a high level of member satisfaction with services.
- Performs clinical reviews, service authorization and care coordination (or oversight and supervision) for all Health Plan members receiving services.
- Complete Annual Competencies including Ethics and Compliance, HIPAA, Safety, Fraud and Abuse and Confidentiality/Privacy and Security Awareness.
- Provide reports on case management cases or activities as requested.
- Perform in accordance with system-wide competencies/behaviors.
- Appropriate documentation in the care management documentation system including assessments, problems, goals and interventions.
- Assumes responsibility for health plan member's access to in-plan and/or supplemental services as medically indicated
- Interfaces with and refers members to community based resources and other supportive services as appropriate.
- Maintains an understanding of behavioral health benefits and remains current on covered or in-plan services, benefit limitations, exclusions, and behavioral health management policies and procedures.
- Participate in integrated care team meetings in a cross cultural environment to coordinate transitions of care, discharge planning, benefit coverage, conflict resolution and resource needs.
- Conduct comprehensive assessment of needs and coordination of care activities for individuals with primary diagnosis of alcohol or substance use addiction
Qualifications
- Master's degree in human service field plus licensure required or Licensed Pennsylvania RN with 6-8 years clinical experience required.
- Five years of experience in clinical, care coordination, and/or case management required.
- OB/Maternity experience highly preferred.
- Homecare experience highly preferred.
- Three years of experience in a managed care environment preferred.
- General knowledge of best practices in health care, emphasizing work with special needs populations and in provider systems.
- Ability to interact with physicians and other health care professionals in a professional manner required. Computer proficiency required.
- Experience with Microsoft office products preferred.
- Excellent verbal and written communication and interpersonal skills required.
- Knowledge of community resources required.
Licensure, Certifications, and Clearances:
- Registered Nurse (RN) or Social Services Licensure (LSW, LCSW, LPC)
- Licensure in other states as assigned
- Case management certification or approved clinical certification preferred
UPMC is an Equal Opportunity Employer/Disability/Veteran
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