The Care Manager coordinates the clinical and financial plan for patients. Care Managers perform overall utilization management, resource management, discharge planning and post-acute care referrals and authorizations while with multi-disciplinary team in resource management, discharge planning and care facilitation.
Responsibilities
Evaluates patient records and applies InterQual criteria to ensure appropriate level of care and authorization compliance.
- Coordinates discharge planning, post-acute services, and transitions of care with patients, providers, payers, and community resources.
- Collaborates with interdisciplinary teams to address barriers, manage denials and appeals, and optimize length of stay.
- Ensures compliance with regulatory, payer, and organizational requirements while promoting patient safety and quality outcomes.
Serves as a clinical resource for documentation, coverage determinations, and care management processes.
- Graduate of approved school of nursing.
- BSN preferred
- Two years of nursing experience required.
- Previous case management experience preferred.
- Knowledge of healthcare financial and payor issues preferred.
- Knowledge of state, local, and federal programs preferred.
- Use of InterQual criteria preferred.
Licensure, Certifications, and Clearances:
- Current licensure as a Registered Professional Nurse either in the state where the facility is located or in a state covered by a licensure compact agreement with the state where the facility is located.*
- Employees practicing in Pennsylvania: UPMC Corporate Care Management Training Certificate of Completion required with 4-6 weeks of hire. UPMC approved Care Management certification preferred.
Act 33 / Act 34 / Act 73 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