Description

UPMC Community Care Behavioral Health is seeking a full-time Precertification Care Manager to support the Precertification Department in a fully remote capacity!

The Precertification Care Manager will be able to work completely from home, as long as they have a private, secure home office space to protect the privacy of members/patients and their information. Individuals hired into this role must live within Pennsylvania, with candidates within approximately two hours of a CCBH office being prioritized.

This position will work a Tuesday through Saturday schedule, with 1 p.m. to 9:30 p.m. hours on Saturdays, and a schedule of 3:30 p.m. to midnight Tuesday through Friday. Rotating holiday and night availability is required within the office, as the CCBH Precertification department is a 24/7 operation.  

The Care Manager is responsible for assisting members identified as at-risk for recidivism, discontinuous care, or as members of priority or special needs populations who present with complex needs for coordination of their behavioral health services with other aspects of their care. This role is responsible for assisting these assigned members with care at all levels of the continuum, and for providing any and all required pre-certification, continued stay and/or discharge reviews, service authorization, and care coordination, as needed.

Care Managers represent the organization to providers, member groups, and families, and participate in the overall administration of clinical operations as warranted. This role is expected to bring a level of clinical leadership to the care management department, and to execute their responsibilities consistent with the applicable Community Care Policies and Procedures. Care managers are specifically chosen based on a targeted area of practice, supported by education, training, and experience, with expertise in the delivery of behavioral health care to a given population. In addition, the Care Manager may serve as the care management lead for other members of his/her team.

Responsibilities:

• Makes authorization determinations for medically necessary services independently, within the scope of the practice of held licensure.
• Demonstrates knowledge of clinical treatment, case management, and community resources.
• Encourages coordination of care with primary care physicians and other service providers integral to the member's life.
• Monitors and evaluates effectiveness and outcome of treatment and service plans.
  • Recommends modifications, as necessary, to provide optimal clinically appropriate services with a goal of maintenance in the community at the least restrictive level of care.
• Assists assigned members with smooth transition when moving into or out of the county.
• Demonstrates excellent clinical, written, and oral communication skills.
• Responds to deadlines and has work completed on or before the deadline 95% of the time.
• Develops specific outreach plans for assigned members who do not maintain regular contact with their behavioral health provider, as recommended, contributing to frequent crises, recidivism, and interfering with maximum benefit from available care.
• Implements appropriate clinical interventions to ensure optimal clinical and quality outcomes for members.
• Works with Member Services, Network Management, and Quality Management staff to ensure that systematic revisions to improve services are developed and implemented.
• Assists with coordinating information and making presentations to participating providers, state and federal agencies, community groups, and other interested parties.
• Identifies provider issues and recommendations for improvement.
• Assumes responsibility for a designated client caseload.
• Provides members, providers, and other stakeholders with accurate information concerning behavioral health care benefits and coverage.
• Facilitates linkages for members and families between primary care and behavioral health providers and other social service or provider agencies as needed to develop and coordinate service plans.
• Maintains contact with and refers members to community-based case management services, as appropriate.
• Possesses excellent clinical skills with sophisticated understanding of the overall needs of individual members assigned.
• Consults with appropriate physician advisors, as needed, for case collaboration and care planning.
• Attends case conferences and interagency and provider treatment planning meetings for assigned members.
• Participates in professional development activities.
• Works as part of a team providing clinical expertise and knowledge to member services and other care management staff.
• Supervises collection of information regarding the delivery and outcomes of services to members, and uses that information to recommend modifications to plan policies and procedures which improve the delivery of services to members.
• Coordinates, reviews, and maintains daily logs for reporting purposes and for weekly preparation and analysis of trending reports.
• Collaborates with providers and others in order to obtain initial assessment, treatment planning, and aftercare planning for members.
• Conducts all clinical reviews, service authorization, and care coordination (or oversight and supervision) for all assigned members receiving behavioral health services.
• Independently problem-solves based on advanced-level knowledge of the service delivery system, the provider network, member services policies, members' rights and responsibilities, and the operating practices of the organization.
• Proposes and implements creative solutions to member problems and to achieve a high level of member satisfaction with services.
• Maintains an understanding of behavioral health benefits and remains current on covered benefits, limitations, exclusions, and policies and procedures regarding services.
• Utilizes supervision with medical director and clinical manager regularly.
• Participates in CQI activities and provider training.
• Works with members and providers to customize services to best meet members' needs within the scope of Community Care's obligations to its members.
• Receives and responds to complex and crisis calls.
• Responds to member and provider complaints according to Community Care's policies and procedures.

Qualifications

• Pennsylvania Licensure in health or human services field and Master's Degree, OR licensed RN (BSN preferred).
• Minimum of three years of relevant clinical experience.
• Experience with both adult and child/adolescent populations and mental health and substance use disorder services strongly preferred.
• Experience in managed care strongly preferred.
• General knowledge of best practices in behavioral health, emphasizing work with special needs or priority populations and in public sector systems.
• Certification in substance use disorders helpful.
• PCPC 3rd Edition, ASAM, and Confidentiality Training preferred.
• Supervisory or other leadership experience in behavioral health also preferred

Licensure, Certifications, and Clearances:
Pennsylvania Licensure: RN, LSW, LCSW, LPC, licensed MFT, and/or a licensed PhD (psychologist). 

• Clinical Social Worker (CSW) OR Licensed Marriage & Family Therapist OR Licensed Professional Counselor (LPC) OR Licensed Social Worker (LSW) OR Psychologist OR Registered Nurse (RN)
• Act 33 
• Act 34 
• Act 73 FBI Clearance 

UPMC is an Equal Opportunity Employer/Disability/Veteran

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