UPMC UM Care Manager – LTSS (Long Term Services & Supports) in Pittsburgh, Pennsylvania
Are you a nurse who is experienced in the field of utilization review or utilization management? Do you thrive on working in a professional environment with other team members? Are you interested in new and exciting changes in healthcare? This may be a perfect opportunity for you! UPMC Health Plan is looking to a hire 2 full-time Utilization Management (UM) Care Managers to support the LTSS (Long Term Services & Supports) team of our Medical Management Clinical Operations department at our location in Downtown Pittsburgh. This position will work primarily with inpatient and prior-authorizations.
This position will work standard daylight hours, Monday through Friday.
The Utilization Management (UM) Care Manager is responsible for utilization review of health plan services and assessment of member's barriers to care, as well as actively working with providers and assessing members to ensure a safe and coordinated discharge from an inpatient setting. You will interact daily with facility clinicians, physicians, and UPMC Health Plan care managers and Medical Directors as part of the member treatment team. You will facilitate transitions in care for skilled nursing, rehabilitation, long term acute care, as needed. Additionally, you will coordinate with Health Plan case managers, service coordinators, or health management staff members to follow-up after discharge from an inpatient setting. You will also provide guidance and assistance to providers and members to ensure that health care needs are met through the delivery of covered services in the most appropriate setting and cost - effective manner.
• 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.
• Identify potential quality of care concerns and never events and refers to health plan quality management department.
• Maintain communication with health care providers regarding health plan determinations.
• Obtain documentation to support 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 medical necessity for requested service.
• 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.
• 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.
• 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.
• 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
Licensure, Certifications, and Clearances:
• Case management certification or approved clinical certification preferred
• Registered Nurse
UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities