Professional Care Manager- Hillman Cancer Center

UPMC; Pittsburgh (Allegheny County); On-site; USD 60,000 - 100,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated Professional Care Manager to join their team at the Hillman Cancer Center. This role involves coordinating clinical and financial plans for patients, ensuring safe discharges, and collaborating with a multidisciplinary team to optimize patient care. The ideal candidate will have a strong nursing background, preferably with case management experience and knowledge of healthcare financial issues. This is an exciting opportunity to make a significant impact in patient care within a supportive and dynamic environment.

Qualifications

• Graduate of an approved nursing program with two years of nursing experience.
• Knowledge of healthcare financial and payer issues preferred.

Responsibilities

• Coordinate clinical and financial plans for patients, ensuring compliance with regulations.
• Review medical records and collaborate with physicians for discharge planning.

Skills

Nursing Experience

Case Management

InterQual Criteria

Patient Safety

Education

Bachelor of Science in Nursing (BSN)

Registered Nurse License

Job description

Professional Care Manager- Hillman Cancer Center

Join to apply for the Professional Care Manager- Hillman Cancer Center role at UPMC

Shift: Monday - Friday 8am - 4:30pm

Purpose: The Care Manager (CM) coordinates the clinical and financial plan for patients. Performs utilization management, resource management, discharge planning, and post-acute care referrals and authorizations. Collaborates with a multidisciplinary team in resource management, discharge planning, and care facilitation.

Responsibilities:

• Review medical records daily to ensure patient meets Level of Care (LOC) requirements and documentation supports LOC determination. Collaborate with Physician Advisor and Attending Physicians to obtain necessary documentation, adjust LOC as needed, and expedite discharge planning.
• Coordinate with patients, caregivers, healthcare providers, agencies, and payers to plan and execute safe discharges. Re-evaluate and revise discharge plans based on patient condition. Develop multiple discharge plans for post-acute services. Use InterQual criteria to justify appropriate LOC and obtain necessary payer authorizations. Document Freedom of Choice regarding post-acute services.
• Serve as a resource for clinical and finance teams on documentation requirements, level of care, insurance coverage, payer policies, and post-acute services coverage.
• Attend departmental meetings and training sessions to stay current on payer and regulatory requirements, policies, and community resources. Ensure compliance with regulations.
• Promote patient safety and support CORE measures for JCAHO requirements.
• Lead in the concurrent denial process, working with the care team to obtain necessary documentation and support LOC decisions. Initiate appeals when appropriate.
• Begin discharge planning on admission, update documentation regularly, and identify barriers to discharge. Work with the team to expedite care, monitor length of stay, and facilitate discharge, documenting all avoidable days.
• Perform clinical review on admission and/or continued stay using InterQual criteria to determine appropriate care level. Obtain all necessary authorizations for admission and continued stay, following payer-specific requirements.

Qualifications:

• Graduate of an approved nursing program.
• Two (2) years of nursing experience required.
• BSN or related bachelor's degree preferred.
• Previous case management experience and 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 Nurse in the state of practice or a multistate license under NLC.
• UPMC Corporate Care Management Training Certificate of Completion required within 4-6 weeks of hire.
• UPMC approved Care Management certification preferred.
• Other certifications include: RN license, Act 34 clearance.

Additional Information:

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Other
• Industries: Hospitals and Health Care