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Job Description

Job Title: Manager, Care Management (RN) - Utilization Management
Job ID: 685927960
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 a nurse with strong experience working in utilization management or utilization review? Do you have proven leadership ability and are ready to take on the challenge of leading dynamic nursing teams to achieve quality outcomes? Don't miss out on this fantastic brand new opportunity! UPMC Health Plan is hiring a full-time Manager, Care Management to support our nursing Utilization Management teams, focused on providing UM and authorization service to providers. These teams are a division of our Medical Management Clinical Operations department.

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

 

The Manager is responsible for the operational functions of the utilization management team including the direct supervision, coaching and counseling of clinical staff. In this role, you will collect and monitor reports related to staff performance and review that performance against Health Plan goals. You will complete staff evaluations and make recommendations for improvement. Your contributions to program evaluations for clinical initiatives that enhance member satisfaction, improve quality of care, and reduce cost are essential. Upon request, you may represent the director by servicing as a liaison to internal departments and government or employer-based agencies.


Responsibilities:

  • Provide staff with applicable regulatory guidelines related to their departmental expectations (I.E. NCQA, DPW, CMS). Consistently monitor and work with internal compliance departments to ensure adherence.
  • Facilitate detailed case reviews with appropriate Health Plan team members including medical directors and other members of the interdisciplinary team to identify barriers to care and initiate appropriate team coordination. Assist staff in making referrals to community or governmental agencies to coordinate levels of service across all Health Plan functional areas. As appropriate manage and assist with discharges or transfers to appropriate level of care.
  • Ensure adherence to department guidelines related to orientation of staff and documentation of staff competency including compliance with government training requirements
  • Assists in the development and implementation of new or revised programs, policies or procedures. Monitor progress, develop recommendations for improvement, and monitor action plans to ensure the integrity of the programs are maintained and deadlines are met. Assist with integrating HP programs across the Health System and vendors as needed.
  • Consistently recognize staff contributions through performance evaluations and nomination for system and health plan staff recognition programs. Complete performance evaluations within departmental timeframes.
  • Conducts regularly scheduled team meetings to communicate key information, engage staff in daily operations, and provide ongoing staff education.
  • Supports supervisors with problem-solving and managing case referrals and work flows according to established program descriptions. Utilize evidence based practice to support improvement in care / health / utilization management.
  • Monitor, coach and report staff activity and productivity; Assist with analysis and monitoring of key financial and utilization targets and trends. Complete quality audits and team reports within departmental timeframes. 

Qualifications

  • Master's degree in nursing or related field required.
  • Minimum of 2 years of nursing experience required.
  • Minimum of 4 years of care manager experience required.
  • Three years of experience in a managed care environment preferred.
  • Prior management, supervisory, or leadership experience required.
  • Case management certification or approved clinical certification required OR 2 years health plan management experience required.
  • Previous utilization management/utilization review experience strongly preferred.
  • Ability to analyze data and identify trends.
  • Proficiency with Microsoft Office products Excellent interpersonal and communication skills (verbal and written).
  • Ability to collaborate effectively with physicians and other health care professionals.
  • Strong organizational and problem solving skills with ability to make decisions independently.
  • Ability to develop and maintain effective team-focused working environment

Licensure, Certifications, and Clearances:

  • Case management certification or approved clinical certification required or 2 years health plan management experience required
  • Registered Nurse (RN)
UPMC is an Equal Opportunity Employer/Disability/Veteran

Salary Range: $35.66 to $60.38 / hour

Union Position: No

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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!

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DIGNITY & RESPECT
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