[Hiring] Behavioral Health UM Care Manager (RN) @UPMC

Role Description

UPMC Health Plan is hiring a part-time UM Care Manager to join the UM Clinical Operations team. This role will work remotely, with scheduled hours falling between 8:00 AM and 4:30 PM EST, Monday through Friday.

The Utilization Management (UM) Care Manager is responsible for:

• Utilization review of health plan services
• Assessment of member's barriers to care
• Working with providers and assessing members to ensure a safe and coordinated discharge from an inpatient setting
• Interacting daily with facility clinicians, physicians, and UPMC Health Plan care managers and Medical Directors as part of the member treatment team
• Facilitating transitions in care for skilled nursing, rehabilitation, long term acute care, as needed
• Coordinating with Health Plan case managers or health management staff members to follow-up after discharge from an inpatient setting
• Providing 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 include:

• Reviewing and documenting clinical information from health care providers including clinical history, home environment, support system, available caregiver, cognitive and psychological status
• Conducting 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
• Working closely with peers and other departments to determine discharge needs including necessary referrals to health plan care management for short or long term interventions
• Obtaining documentation to support requested level of care within the defined health plan regulatory timeframes and providing verbal and/or written notification to providers as applicable
• Consulting with health plan medical director to discuss medical necessity for requested service
• Maintaining communication with health care providers regarding health plan determinations
• Participating in health plan interdisciplinary team conferences and collaborative case reviews to discuss complex cases and determine appropriate discharge plan or level of service
• Identifying potential quality of care concerns and never events and referring to health plan quality management department
• Documenting all activities in the Health Plan's care management tracking system following Health Plan and internal department standards
• Identifying trends and opportunities for improvement based on information obtained from interaction with members and providers

Qualifications

• Minimum of 2 years of experience in a clinical and/or case management nursing required
• BSN or MSN strongly preferred
• Prior UM experience strongly preferred
• Prior psych experience strongly preferred
• PA RN license strongly preferred
• Work experience of 1 year discharge planning preferred
• Strong organizational, task prioritization and problem-solving skills
• Ability to construct grammatically correct reviews using standard medical terminology
• Computer proficiency required

Requirements

• Case management certification or approved clinical certification preferred
• Registered Nurse (RN)
• Act 34
• Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state
• Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state

Company Description

UPMC is an Equal Opportunity Employer/Disability/Veteran