Description

The Care Manager (CM) coordinates the clinical and financial plan for patients. CM's perform overall utilization management, resource management, discharge planning and post-acute care referrals and authorizations. CM's also work with multi-disciplinary team in resource management, discharge planning and care facilitation.

Title and Rate of Pay will be based on Education and Experience
 

Responsibilities:

• 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.
• 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.
• 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.
• 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.
• Promotes patient safety. Supports CORE measures information for JCAHO requirements.
• 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.
• 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.
• 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.

Qualifications

• Graduate of approved school of nursing.
• 2 years of nursing experience required.
• BSN or related Bachelors degree 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:

• Employees practicing in Pennsylvania: UPMC Corporate Care Management Training Certificate of Completion required with 4-6 weeks of hire.
• UPMC approved Care Management certification preferred.
• Registered Nurse (RN)
• Act 33 with renewal
• Act 34 with renewal
• Act 73 FBI Clearance

UPMC is an Equal Opportunity Employer/Disability/Veteran

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