The Care Manager is responsible for inpatient/ambulatory workflows and day-to-day operations for their designated inpatient unit/ambulatory program.Responsibilities:
Maintain a thorough understanding of Care Management processes as established by industry standards. Gather and maintain current patient progress from the medical record and treatment team meetings. Complete Care Management reviews according to established medical necessity criteria. Complete Care Management reviews within payer timelines. Document pertinent clinical information on the Care Management Abstract. Complete accurate, timely, and thorough documentation in electronic applications (e.g., HealthPlaNET, EPIC). Demonstrate proficiency in IT applications/portals (e.g., HealthPlaNET, Cerner, EPIC, payor portals)Effective communication with WPH management team regarding authorization challenges. Coordinate MD-MD reviews with the MDs and Care Management administrative staff. Assist with the appeal process (e.g., creating and updating denial tracking sheets) Participate in telecons, grievance hearings, and DHS pre-hearings/hearings as needed. Assist with the resolution of billing questions and/or denials.
Develop and sustain collaborative working relationships with other WPH departments (e.g., Patient Access, PES, PC+, Fiscal) as well as with external insurers. Display effective problem-solving skills. Demonstrate effective communication skills both verbal and written. Display a positive attitude, be a helpful team member. Participate in departmental improvement projects. Proficiency in Microsoft Office applications. Perform in accordance with system-wide competencies/behaviors. Complete other related duties as assigned.
Bachelor’s degree in Human Services or related field with 3 years of clinical experience or healthcare experience
OR
Licensed RN with BSN with 3 years of clinical experience or healthcare experience
OR
Master’s degree in Human Services or related field with 1 year of clinical experience or healthcare experience.
Care Management experience preferred.
Behavioral Health experience preferred.
Licensure, Certifications, and Clearances:
Registered Nurse (RN)
Act 31 Child Abuse Reporting with renewal
Act 33 with renewal
Act 34 with renewal
Act 73 FBI Clearance with renewal
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
