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    Care Manager - Pittsburgh, United States - UPMC

    UPMC
    UPMC Pittsburgh, United States

    1 week ago

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    Description
    The Care Manager will assist the inpatient treatment teams to ensure appropriate level of care for all patients.

    The Care Manager will coordinate insurance reviews including pre-certification, continued stay reviews, retrospective reviews, and denial/appeal activity and documentation as needed.

    This department supports hospital operations for both inpatient and ambulatory services. The schedule is Monday through Friday 8:30am to 4:30pm located at Western Psychiatric Hospital.


    Responsibilities:

    • Completes pre-certification and continued stay reviews within the designated MCO timeframes. Gathers and maintains current patient progress from unit documentation, treatment team meetings, disposition meetings, etc. Coordinates MD-MD reviews with the MDs and CM administrative staff. Maintains a thorough understanding of Care Management standards and processes as defined the various managed care organizations. Writes letters for provider appeals, member grievances, & DPW requests. Participates in telecons, grievance hearings, and DPW pre-hearings/hearings. Reviews and completes MA late pick-up Completes accurate, timely, and thorough documentation in the Psych Consult Care Management application. Documents pertinent clinical information on the Care Management Abstract. Collaborates with multiple departments within UPMC (e.g. Fiscal, Patient Access, DEC, and PBS).Displays a positive attitude and be a helpful team member within the CM department. Effective communication with WPIC management regarding authorization challenges. Participates in departmental performance improvement projects.
    • Maintain a thorough understanding of Care Management processes as established by industry standards. Complete Care Management reviews according to established medical necessity criteria. Complete Care Management reviews within payer timelines. Complete accurate, timely, and thorough documentation in HealthPlaNET. Demonstrate proficiency in HealthPlaNET and other IT applications/portals (e.g., Cerner, EPIC)Assist with the appeal process (e.g., creating and updating denial tracking sheets) Participate in telecons, grievance hearings, and DHS pre-hearings/hearings. Assist with the resolution of billing questions and/or denials. Develop and sustain collaborative working relationships with other WPH departments (e.g., Patient Access, PES, PC, Fiscal) as well as with external insurers.
    • Bachelor's degree in Human Services or related field with 3 years of clinical experience
    Or

    • RN with 3 years of clinical experience
    Or

    • Master's degree in Human Services or related field with 1 year of clinical experience.
    • Managed Care Experience preferred.

    Licensure, Certifications, and Clearances:

    • Registered Nurse (RN)
    • Act 31 Child Abuse Reporting with renewal
    • Act 33 with renewal
    • Act 34 with renewal
    • Act 73 FBI Clearance with renewal
    *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.

    _UPMC is an Equal Opportunity Employer/Disability/Veteran_
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