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   Current UPMC employees must apply in HR Direct

Lead Care Manager - Collaborative Case Management

Description

In addition to staff level care management responsibilities for unit specific population, assists in the operational activities of staff in the Care Management Department including the facilitation of care and services to patients and families across the continuum of illness. Assists the Director with staff orientation, mentoring and other operational issues.

Responsibilities:

  • 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.
  • Examines and implements strategies to reduce patient complications and resource consumption for the case managed patient population. Can function independently and effectively to solve problems. Appropriately refers problem cases to the director of care management and/or medical staff leadership for expedient action or problem resolution.
  • Assists in the daily activities of the Care Management staff including making adjustments to staffing assignments as indicated.
  • Participates in the development of division goals and objectives in conjunction with the hospitals mission, strategic priorities and performance improvement plan.
  • 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.
  • Facilitates the development of educational materials for the department including an orientation program, job specific competencies, and continuing education.
  • Audits and evaluates the daily activates of Care management staff including utilization review, discharge planning, documentation, and interdisciplinary rounds.
  • 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.
  • Utilizes innovative strategies to meet patient care needs when the plan of care meets or exceeds health benefits coverage limitations.
  • Promotes patient safety. Supports CORE measures information for JCAHO requirements.
  • 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 discharge 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.
  • Participates in the development/revision of departmental policies and procedures. Maintains and updates resource materials for staff.
  • Develops internal and external customer relationships (medical staff, employees, families, payer groups, etc.) Identifies customer needs, develops systems to monitor satisfaction and develops plans to address areas of dissatisfaction.
  • 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.
  • Acts as a mentor to staff to ensure departmental standards are met. Provides input to the manager/Director in the evaluation of staff and participates in the performance review process.
  • Develops and maintains a positive working relationship with the medical staff and health care team. Facilitates and arbitrates differences and disagreements. Uses diplomacy and negotiation skills to mediate conflict and achieve team objectives. Incorporates and promotes service excellence principles and strategies into daily work.

 

Qualifications

  • BSN/BS in related field
  • 3 YOE required
  • 2 YOE in Care Mgmt
  • PLUS 1 YOE in leadership OR 1 YOE as Sr. Prof. Care Mgr.


Licensure, Certifications, and Clearances:

  • Current Nursing Licensure in the Commonwealth of Pennsylvania.
  • UPMC approved Care Management certification required within one year of hire.Other Requirements:Identification and successful completion of an approved professional contributionCPR required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire
  • Registered Nurse (RN)
  • Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran

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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.

   Current UPMC employees must apply in HR Direct