UM Care Manager (RN) - Flex Full-Time

UPMC; Pittsburgh (Allegheny County); On-site; USD 60,000 - 90,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Retirement plan

Paid time off

Job summary

UPMC Health Plan is hiring a flex full-time UM Care Manager to support our UM Clinical Operations team. The role involves 8-10 hour Saturday shifts with flexible weekday scheduling based on team needs and employee preference.

The candidate will work a minimum of 28 hours per week with potential up to 40 hours, enjoying full-time benefits including medical, dental, and vision coverage, retirement, PTO, and life insurance.

Responsibilities

• Obtain documentation to support requested level of care within regulatory timeframes and notify providers as applicable.
• Document activities in the care management tracking system per standards; identify trends for improvement.
• Review clinical information from providers (history, home environment, status) for authorization.
• Participate in interdisciplinary team conferences to discuss discharge plans.
• Collaborate with peers and departments to determine discharge needs and referrals.
• Maintain communication with providers regarding care plan determinations.
• Identify quality of care concerns and refer to quality management as needed.

Job description

UPMC Health Plan is hiring a flex full-time UM Care Manager to support our UM Clinical Operations team. This role will work 8 - 10 hours shifts on Saturdays with some flexible weekday scheduling based on employee preference and team scheduling.

As a flexible full-time employee, you are guaranteed to work a minimum of 28 hours per week with opportunity to work up to 40 hours per week as needed by the department and your own preference. Flexible full-time employees receive regular full-time benefits, including medical, dental, and vision coverage, a retirement plan, paid time off, life insurance, and more!

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. Interacts daily with facility clinicians, physicians, and UPMC Health Plan care managers and Medical Directors as part of the member treatment team. Facilitates transitions in care for skilled nursing, rehabilitation, long term acute care, as needed. Coordinates with Health Plan case managers or health management staff members to follow-up after discharge from an inpatient setting. Provides 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.

Responsibilities:

• 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.
• 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.
• 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.
• 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.
• 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.
• Maintain communication with health care providers regarding health plan determinations.
• Identify potential quality of care concerns and never events and refers to health plan quality management department.