Clinical Care Coordinator
3 weeks ago
The Care Manager at UPMC is responsible for coordinating the clinical and financial plan for patients. This involves performing overall utilization management, resource management, discharge planning, and post-acute care referrals and authorizations. The Care Manager works with a multi-disciplinary team in resource management, discharge planning, and care facilitation.
This position requires a graduate of an approved school of nursing with two years of nursing experience. A BSN or related Bachelor's degree is preferred, as is previous case management experience. Knowledge of healthcare financial and payor issues, as well as state, local, and federal programs, is also preferred. The use of InterQual criteria is preferred.
Responsibilities:
- Reviews medical records daily to ensure patients continue to meet LOC requirements and that chart documentation supports LOC determination.
- Works with Physician Advisors 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 plans as patient clinical conditions merit.
- Develops alternative/multiple discharge plans in anticipation of patient need for post-acute services.
- Uses InterQual criteria to justify appropriate LOC and obtain all necessary payer authorizations for post-acute care.
- Documents Freedom of Choice regarding post-acute services.
- 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 Corporate Care Management Training sessions to maintain current knowledge of all payer and regulatory requirements, UPMC CM policies and procedures, and community resources.
- Ensures compliance with all payer and government regulations.
- Promotes patient safety and supports CORE measures information for JCAHO requirements.
- Takes a leadership role in concurrent denial process.
- Works with Care Management Director, Physician Advisors, Attending Physicians, and clinical teams 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 teams to expedite care, monitor length of stay, and facilitate discharge.
- Addresses complex clinical and social situations efficiently 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 and obtains all necessary authorizations for level of care, including admission and continued stay.
- Follows payer-specific requirements to obtain and document authorizations.
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.
- UPMC Corporate Care Management Training Certificate of Completion required with 4-6 weeks of hire.
- UPMC approved Care Management certification preferred.
- Advanced Cardiac Life Support (ACLS).
- Registered Nurse (RN).
- Act 34 with renewal.
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