UPMC Professional Care Manager (RN) in Pittsburgh, Pennsylvania
Are you an experienced nurse with previous inpatient and/or pediatric nursing experience looking to start or further your career in care management? We are looking for you!
UPMC Children's Hospital of Pittsburgh seeks a Full Time Professional Care Manager to coordinate the care plan for its patients. The Care Manager 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.
The Professional Care Manager is a valued step in the UPMC nursing career ladder, with opportunities for continued growth and upward advancement.
The Care Manager (CM) coordinates the clinical and financial plan for patients. Performs overall utilization management, resource management, discharge planning and post-acute care referrals and authorizations. Works with multi-disciplinary team in resource management, discharge planning and care facilitation.
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.
Graduate of approved school of nursing
Two (2) years of nursing experience required
Pediatric nursing experience strongly preferred
BSN or related Bachelors degree strongly preferred
Previous case management experience preferred
Previous inpatient or home health care nursing experience strongly 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
Act 33 Child Clearance with Renewal
Act 34 Criminal Clearance with Renewal
Act 73 FBI Clearance
UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities REQNUMBER: 697598