Professional Care Manager

UPMC Children's Hospital Of Pittsburgh Care Manager

Regionally, nationally, and globally, UPMC Children's Hospital of Pittsburgh is a leader in the treatment of childhood conditions and diseases, a pioneer in the development of new and improved therapies, and a top educator of the next generation of pediatricians and pediatric subspecialists. With generous community support, UPMC Children's Hospital has fulfilled this mission since its founding in 1890.

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.

This position may require occasional Weekend and Holiday Hours

Responsibilities:

• 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.
• 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.
• 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.
• 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.
• Promotes patient safety. Supports CORE measures information for JCAHO requirements.
• 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.
• 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.
• 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.

Qualifications:

• Two years of nursing experience required.
• BSN or related Bachelors degree preferred.
• Previous case management experience preferred.
• Previous In-Patient Hospital experience 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:
• Current licensure as a Registered Professional Nurse either in the state where the facility is located or in a state covered by a licensure compact agreement with the state where the facility is located.*
• Employees practicing in Pennsylvania: UPMC Corporate Care Management Training Certificate of Completion required with 4-6 weeks of hire.
• UPMC approved Care Management certification preferred.

*Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran