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Job Description

Job Title: Professional Care Manager
Job ID: 758179293
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: Pinnacle Health Medical Group
Department: Care Management Team
Location: 2601 North Third Street, Harrisburg PA 17110

Description

Professional Care Manager:
The Professional Care Manager is responsible for the coordination of care for patients who have complex medical and/or psychosocial needs and who require intensive care management. Patients with complex needs will be routinely identified through case review, referral from inpatient case management, referral from physician practices, predictive analytics, and other reliable data sources. This individual plays a pivotal role in the Patient Centered Medical Home (PCMH) by collaborating with the primary care physicians and an interdisciplinary team to develop a plan of care for the highest risk patients. The care manager establishes an interdisciplinary approach in working with patients, families, and the care team (e.g. social work, inpatient and specialist care coordinators, pharmacist, etc.) to utilize evidence-based resources to establish appropriate interventions and goals of care. This individual implements, coordinates, monitors, and evaluates appropriate resources using evidenced based standards. The goals of care management are to maintain clinical stability, promote appropriate utilization of services, enhance patients' ability to better manage their health and disease, and improve the patient's health status, clinical outcomes, and satisfaction.

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.Two (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:
Currently licensed as professional nurse in the Commonwealth of PA. UPMC Corporate Care Management Training Certificate of Completion required with 4-6 weeks of hire. UPMC approved Care Management certification preferred

  • Driver's License
  • Registered Nurse (RN)
  • Act 33 with renewal
  • Act 34 with renewal
  • Act 73 FBI Clearance with renewal

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

    Salary Range: $29.75 to $46.13 / hour

    Union Position: No

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