- Entry level
- No Education
- Salary to negotiate
The Senior Care Manager (CM) coordinates the clinical and financial plan for patients. Performs overall utilization management, resource management, discharge planning and post-acute care referrals and authorizations. Works with multi-disciplinary team in resource management, discharge planning and care facilitation.
- Collaborates with patients, caregivers, internal/external healthcare providers, agencies and payers to plan and execute a safe discharge. Re-evaluates and revises discharge plan as patient clinical condition merits. Develops alternative/multiple discharge plans in anticipation of patient need for post-acute services. Uses InterQual criteria to justify appropriate LOC (Skilled, Rehab, Home Care, DME, etc.) and obtain all necessary payer authorizations for post-acute care. Documents Freedom of Choice re: post-acute services.
- Reviews medical record daily to ensure patient continues to meet LOC requirements and that chart documentation supports LOC determination. Works with Physician Advisor 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.
- Starts discharge planning on admission and ensures DC documentation is completed and updated regularly. Proactively identifies barriers to discharge and works with multi-disciplinary team to expedite care, monitor length of stay (LOS) and facilitate discharge. Addresses complex clinical and social situations efficiently in order to avoid unnecessary delays in discharge. Documents all Avoidable Days in CANOPY system.
- Takes leadership role in concurrent denial process. Works with Care Management Director, Physician Advisor, Attending Physicians and clinical team 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.
- Promotes patient safety. Supports CORE measures information for JCAHO requirements.
- Evaluated issues, trends and recommends improvement to Care Manger Manager/Director and/or multi-disciplinary team.
- Serves as a role model of excellent customer service and patient care.
- Promotes advancement of knowledge and skills of other disciplinary teams and lay members of the community by serving as a resource to internal and external individual groups.
- Serves as 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.
- Performs clinical review on admission and/or continued stay using InterQual criteria to determine appropriate level of care (Inpatient, OBS, etc.) Obtains all necessary authorizations for level of care including admission and continued stay. Follows payer-specific requirements to obtain and document authorizations.
- Attends Department meetings and Corporate Care Management Training sessions in order to maintain current knowledge of all payer and regulatory requirements, UPMC CM policies and procedures, community resources. Ensures compliance with all payer and government regulations.
- Serves as a leader within the care management department in completing his/her assignment. Qualifications
Graduate of approved school of nursing.Two (2) years of nursing experience required. BSN or related Bachelors degree required. Two (2) year of care management experience or equivalent experience in the healthcare environment required. Knowledge of healthcare financial and payor issues required. Knowledge of state, local, and federal programs required. Use of InterQual criteria preferred.
Licensure, Certifications, and Clearances:
Currently licensed as professional nurse in the Commonwealth of PA.UPMC Corporate Care Management Training Certificate of Completion required within 4-6 weeks of hireUPMC approved Care Management certification preferred
- Registered Nurse (RN)
- Act 33 with renewal
- Act 34 with renewal
- Act 73 FBI Clearance with renewal
About the company