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   Current UPMC employees must apply in HR Direct

UM Care Manager - Clinical Auditor

Description

Are you an experienced nurse with an interest in gaining knowledge in care management? Do you thrive on working in a professional environment? Our team is growing, and we are looking for you to grow with us! UPMC Health Plan is hiring a full-time Utilization Management Care Manager to support the Clinical Auditing team. This position will work Monday through Friday daylight hours and will predominately be working from home. 

The Utilization Management (UM) Care Manager Clinical Auditing team is responsible for utilization review of health plan services and assessment of member's barriers to care. As part of the compliance auditing team, this position will ensure that all member correspondence contains language that is easy to understand and is member-friendly as well as written at an appropriate educational level.  Conduct various department audits, to ensure that all aspects of the Utilization Management/Clinical Operations department are following the appropriate regulatory/compliance guidelines and protocols. Interacts daily with the Utilization Management/Clinical Operations clinicians and Medical Directors. 

Responsibilities:

  

  • Obtain documentation to support the requested level of care within the defined health plan regulatory timeframes and provide verbal and/or written notification to providers as applicable. Consult with health plan medical director to discuss the medical necessity for requested service.
  • Document all activities in the Health Plan's care management tracking system following Health Plan and internal department standards and identify trends and opportunities for improvement based on information obtained from interaction with members and providers.
  • Review and document clinical information from health care providers including clinical history, home environment, support system, available caregiver, cognitive and psychological status. Conduct clinical reviews for authorization requests using established criteria including Interqual, Mahalik, and health plan policy and procedures for inpatient, outpatient, Durable Medical Equipment (DME), Behavioral Health, and Private Duty Nursing.
  • Participate in health plan interdisciplinary team conferences and collaborative case reviews to discuss complex cases and determine appropriate discharge plan or level of service. Consult with health plan medical director on an as-needed basis to discuss medical necessity for requested service.
  • Work closely with peers and other departments to determine discharge needs including necessary referrals to health plan care management for short or long-term interventions.
  • Maintain communication with health care providers regarding health plan determinations.
  • Identify potential quality of care concerns and never events and refers to health plan quality management department.

 

Qualifications

  • Minimum of 2 years of experience in a clinical and/or case management nursing required
  • Minimum of 1-year work-related experience in Utilization Management required.
  • Work experience of 1-year discharge planning preferred.BSN preferred
  • Strong organizational, task prioritization and problem-solving skills
  • Ability to construct grammatically correct reviews using standard medical terminology
  • Computer proficiency required

Preferences:

  • Excellent writing skills: exceptional knowledge of English writing/grammar. Demonstrated ability to summarize complex and sensitive information, and write reports/letters in a clear, concise, non-judgmental, member-friendly and effective manner.
  • Ability to write complex letters in a concise, cogent manner while establishing patterns and addressing issues in the way resolutions and other information is communicated.
  • Strong analytical, organizational, problem resolution, verbal and written communication skills. High regard for protecting confidentiality of corporate information.
     


Licensure, Certifications, and Clearances:

  • Case management certification or approved clinical certification preferred
  • Registered Nurse (RN)

UPMC is an Equal Opportunity Employer/Disability/Veteran

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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.

   Current UPMC employees must apply in HR Direct