UM Care Manager (RN) - Pediatric

UPMC Health Plan is hiring a full-time Utilization Management (UM) Care Manager to join the UM Clinical Operations team. This position will be work from home and will work Monday - Friday 8 am -4:30 pm EST.

The ideal candidate will reside in Pennsylvania, possess pediatric clinical and/or home care experience, and hold an active Pennsylvania RN license or a multistate RN license.

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.