Senior Professional Care Manager Outcomes Specialist

4 days ago


Mechanicsburg, Pennsylvania, United States UPMC Full time
Job Summary

UPMC is seeking a highly skilled Sr. Professional Care Manager Outcomes Management to join our team. As a key member of our care management department, you will play a critical role in coordinating clinical and financial plans for patients, ensuring seamless transitions and optimal outcomes.

Key Responsibilities
  • Collaborate with patients, caregivers, and healthcare providers to develop and implement individualized care plans.
  • Conduct thorough assessments to determine appropriate levels of care and facilitate timely discharges.
  • Work closely with multidisciplinary teams to identify and address barriers to care, ensuring efficient and effective care transitions.
  • Utilize InterQual criteria to justify levels of care and obtain necessary authorizations.
  • Document all avoidable days in the CANOPY system and take a leadership role in concurrent denial processes.
  • Promote patient safety and support CORE measures for JCAHO requirements.
  • Evaluate issues, trends, and recommend improvements to care management leadership and multidisciplinary teams.
  • Serve as a resource to internal and external stakeholders, providing expertise on clinical documentation requirements, level of care, and insurance coverage issues.
Requirements
  • Graduate of an approved school of nursing.
  • Two years of nursing experience, with at least two years of care management experience or equivalent experience in the healthcare environment.
  • Knowledge of healthcare financial and payer issues, as well as state, local, and federal programs.
  • Use of InterQual criteria preferred.
Licensure, Certifications, and Clearances
  • Currently licensed as a professional nurse in the Commonwealth of PA.
  • UPMC Corporate Care Management Training Certificate of Completion required within 4-6 weeks of hire.
  • UPMC approved Care Management certification preferred.

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