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   Current UPMC employees must apply in HR Direct

Senior Professional Care Manager - General Rehab (UPMC Mercy)

Description

UPMC Mercy seeks a Full-Time Senior Professional Care Manager to coordinate the care plans for our patients. This Senior Professional Care Manager will focus on our General Rehab population.

 

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 Senior 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.

 

**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.**

 

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:

  • 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.

  • 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.

  • 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.

  • Promotes patient safety.

  • Supports CORE measures information for JCAHO requirements.

  • Evaluated issues, trends and recommends improvement to Care Manger Manager/Director and/or multi-disciplinary team.

  • Serves as a role model of excellent customer service and patient care.

  • Promotes advancement of knowledge and skills of other disciplinary teams and lay members of the community by serving as a resource to internal and external individual groups.

  • 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.

  • 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.

  • 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.

  • Serves as a leader within the care management department in completing his/her assignment.

 

Qualifications

  • Graduate of approved school of nursing.

  • Two (2) years of nursing experience required.

  • BSN or related Bachelors degree required.

  • Two (2) year of care management experience or equivalent experience in the healthcare environment required. Knowledge of healthcare financial and payor issues required.

  • 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 within 4-6 weeks of hire.

  • UPMC approved Care Management certification preferred

  • Registered Nurse (RN)

  • Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct