Job Description

Job Title: UM Care Manager (RN)
Job ID: 733714
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: UM Clin Ops
Location: 600 Grant St, Pittsburgh PA 15219

Description

Are you an experienced nurse with an interest in gaining knowledge in care management? Do you thrive on working in a professional environment? Our team is growing, and we are looking for you to grow with us! UPMC Health Plan is hiring a full-time Utilization Management (UM) Care Manager to support the Ancillary Services team in Medical Management Clinical Operations department for our location in Downtown Pittsburgh.

This position will work standard daylight hours, Monday through Friday.

The Utilization Management (UM) Care Manager is responsible for utilization review of health plan services and assessment of member's barriers to care, as well as actively working with providers and assessing members to identify their need(s) for durable medical equipment, parenteral/enteral feedings and home care services.

In this role, you will interact daily with physician offices, vendors, facilities and UPMC Health Plan care managers and Medical Directors as part of the member treatment team. You will coordinate with Health Plan case managers to help identify appropriate services for members. Through collaboration, you will provide guidance and assistance to providers and members to ensure that health care needs are met through the delivery of covered services in the most appropriate setting and cost - effective manner.

Responsibilities:
  • Document all activities in the Health Plan's care management tracking system following Health Plan and internal department standards and identify trends and opportunities for improvement based on information obtained from interaction with members and providers.
  • Identify potential quality of care concerns and never events and refers to health plan quality management department.
  • Maintain communication with health care providers regarding health plan determinations.
  • Obtain documentation to support requested level of care within the defined health plan regulatory timeframes and provide verbal and/or written notification to providers as applicable. Consult with health plan medical director to discuss medical necessity for requested service.
  • Participate in health plan interdisciplinary team conferences and collaborative case reviews to discuss complex cases and determine appropriate discharge plan or level of service. Consult with health plan medical director on an as needed basis to discuss medical necessity for requested service.
  • Review and document clinical information from health care providers including clinical history, home environment, support system, available caregiver, cognitive and psychological status. Conduct clinical reviews for authorization requests using established criteria including Interqual, Mahalik, and health plan policy and procedures for inpatient, outpatient, Durable Medical Equipment (DME), Behavioral Health, and Private Duty Nursing.
  • Work closely with peers and other departments to determine discharge needs including necessary referrals to health plan care management for short or long term interventions.

Qualifications

  • Minimum of 2 years of experience in a clinical and/or case management nursing required
  • Minimum of 1 year work related experience in Utilization Management required (nurses with inpatient experience are encouraged to apply!) 
  • BSN preferred
  • Work experience of 1 year discharge planning preferred.
  • Experience in Discharge Planning, Home Care, and Durable Medical Equipment requirements preferred.
  • Strong organizational, task prioritization and problem solving skills
  • Ability to construct grammatically correct reviews using standard medical terminology
  • Computer proficiency required

Licensure, Certifications, and Clearances:
  • Case management certification or approved clinical certification preferred
  • 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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