Description
Are you an experienced nurse or nurse case manager looking to start or further your career in care management? UPMC Presbyterian Shadyside is looking for Professional / Senior Professional Care Managers to support the Care Management departments for its Shadyside and Oakland locations in the city of Pittsburgh.This position will work standard daylight hours, Monday through Friday.
**Nurses with 2 years of nursing experience may be considered for this position. The title and salary range of the position may vary depending on education level and any years of relevant case management background. Salary range as posted is for a Professional Care Manager.**
The Care Manager, a nurse, is an expert in resource management, a master of regulatory compliance, a superb communicator, and above all a compassionate partner for each individual patient. Able to balance complex clinical scenarios with the patient’s social, emotional, spiritual, and economic needs, the Professional Care Manager is a strong clinician who works closely with physicians, nurses, and other caregivers to assist in progressing the patient along the continuum of care.
Healing is just one aspect of a hospital stay. For patients and their families, there are many clinical opinions, specialist referrals, treatment choices, and financial considerations at play--navigating all of that can be a confusing and overwhelming process. They need an advocate, someone who foresees their needs, knows their options, and begins strategizing their way home from the moment of admission.
An essential member of the care delivery team, you will apply your own judgment and problem-solving skills to ensure each patient is provided with efficient, quality care while minimizing risks, delays, and unnecessary costs. You will work hand-in-hand with the multidisciplinary team as well as internal and external providers and agencies to execute a safe discharge and a clear path forward for patients and their families, including plans for self-management, at-home care, and post-acute referrals and outreach, as needed.
The Professional Care Manager is a valued step in the UPMC nursing career ladder, with opportunities for continued growth and upward advancement.
Responsibilities:
- 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.
- 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.
- 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.
- Promotes patient safety. Supports CORE measures information for JCAHO requirements.
- 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.
- 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.
- 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.
- 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.
Qualifications
- Graduate of approved school of nursing.
- Two (2) years of nursing experience required.
- BSN or related Bachelors degree strongly preferred for Professional level, required for Senior level.
- Two (2) year of care management experience or equivalent experience in the healthcare environment preferred, or required for Senior level
- Knowledge of healthcare financial and payor issues preferred.
- Knowledge of state, local, and federal programs required.
- 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
- Act 34 Criminal Clearance
- Registered Nurse
Individuals hired into this role must comply with UPMC’s COVID vaccination requirements upon beginning employment with UPMC. Refer to the COVID-19 Vaccination Information section at the top of this page to learn more.
Total Rewards
More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life — because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.
Our Values
At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.
