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Care Manager
2 months ago
**Job Summary:**
The Care Manager is a critical role within the University of Pittsburgh Medical Center, responsible for coordinating the clinical and financial plan for patients. This position requires a strong understanding of healthcare financial and payor issues, as well as knowledge of state, local, and federal programs.
Key Responsibilities:
- Reviews Medical Records: The Care Manager reviews medical records daily to ensure patients continue to meet Level of Care (LOC) requirements and that chart documentation supports LOC determination.
- Collaborates with Patients and Healthcare Providers: The Care Manager collaborates with patients, caregivers, internal/external healthcare providers, agencies, and payers to plan and execute a safe discharge.
- Develops and Revises Discharge Plans: The Care Manager develops and revises discharge plans as patient clinical condition merits, using InterQual criteria to justify appropriate LOC and obtain all necessary payer authorizations for post-acute care.
- Serves as Resource to Clinical and Finance Teams: The Care Manager serves as a 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 Training Sessions: The Care Manager attends department meetings and corporate care management training sessions to maintain current knowledge of all payer and regulatory requirements, UPMC CM policies and procedures, and community resources.
- Promotes Patient Safety: The Care Manager promotes patient safety and supports CORE measures information for JCAHO requirements.
- Takes Leadership Role in Concurrent Denial Process: The Care Manager takes a leadership role in the concurrent denial process, working with the Care Management Director, Physician Advisor, Attending Physicians, and clinical team to obtain necessary information and documentation to support LOC.
- Starts Discharge Planning on Admission: The Care Manager starts discharge planning on admission and ensures DC documentation is completed and updated regularly.
- Performs Clinical Review: The Care Manager performs clinical review on admission and/or continued stay using InterQual criteria to determine appropriate level of care (Inpatient, OBS, etc.) and obtains all necessary authorizations for level of care.
Qualifications:
- Graduate of Approved School of Nursing: The Care Manager must be a graduate of an approved school of nursing.
- Two Years of Nursing Experience: The Care Manager must have two years of nursing experience.
- BSN or Related Bachelor's Degree: A BSN or related Bachelor's degree is preferred.
- Previous Case Management Experience: Previous case management experience is preferred.
- Knowledge of Healthcare Financial and Payor Issues: Knowledge of healthcare financial and payor issues is preferred.
- Knowledge of State, Local, and Federal Programs: Knowledge of state, local, and federal programs is preferred.
Licensure, Certifications, and Clearances:
- Current Licensure as a Registered Professional Nurse: The Care Manager must have 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.
- UPMC Corporate Care Management Training Certificate of Completion: The Care Manager must complete the UPMC Corporate Care Management Training Certificate of Completion within 4-6 weeks of hire.
- UPMC Approved Care Management Certification: UPMC-approved Care Management certification is preferred.
