UM Care Manager (RN)

Are you a registered nurse with a background in utilization management? UPMC Health Plan is looking for you!

We are hiring a full-time Utilization Management Care Manager to support the Utilization Management Clinical Operations Department. This position will predominantly work from home, standard daylight hours, Monday through Friday.

The Utilization Management (UM) Care Manager is responsible for utilization review of health plan services and assessment of member's barriers to care. Interacts daily with facility clinicians, physicians, and UPMC Health Plan care managers and Medical Directors as part of the member treatment team. Provides 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:

• Obtain documentation to support requested level of care within the defined health plan regulatory timeframes and provide verbal and/or written notification to providers as applicable. Consult with health plan medical director to discuss medical necessity for requested service.
• Document all activities in the Health Plan's care management tracking system following Health Plan and internal department standards and identify trends and opportunities for improvement based on information obtained from interaction with members and providers.
• Review and document clinical information from health care providers including clinical history, home environment, support system, available caregiver, cognitive and psychological status. Conduct 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.
• Participate in health plan interdisciplinary team conferences and collaborative case reviews to discuss complex cases and determine appropriate discharge plan or level of service. Consult with health plan medical director on an as needed basis to discuss medical necessity for requested service.
• Work closely with peers and other departments to determine discharge needs including necessary referrals to health plan care management for short or long term interventions.
• Maintain communication with health care providers regarding health plan determinations.
• Identify potential quality of care concerns and never events and refers to health plan quality management department.