Purpose:

　　The Care Manager is responsible for coordinating and communicating the discharge plan for targeted residents, promoting delivery of the right care in the right setting and assuring appropriate processes and regulations are followed related to third party payers and financial plans.

　　Responsibilities:

　　Apply clinical knowledge to determine if resident requires a change in level of care or care setting and communicates with physicians and third party payers to facilitate appropriate level of care changes.

　　Educate residents/families and interdisciplinary team regarding third party payor requirements and other aspects related to benefit coverage. e.g., notices of non-coverage.

　　Perform daily clinical review utilizing InterQual criteria as a guide to validate whether resident meets admission or continued stay criteria.

　　Collaborate with the interdisciplinary team to facilitate appropriate discharge.

　　Obtain consent to appeal on behalf of the resident on all final outcome of denial situations.

　　Call payors to obtain authorizations, interpret insurance benefits, review levels of care, and provide requested information.

　　Perform daily medical record reviews, monitoring appropriate length of stay to meet care needs, identifying barriers to discharge, and collaborating with external case managers.

　　Consult with the Physician Advisor when needed to address medical decisions requiring review.

　　Ensure current understanding of guidelines and requirements of payors, external agencies, and regulations.

　　Promote resident safety.

　　Coordinate and facilitate resident progression throughout the continuum of care.

　　2 years nursing experience in LTC/Acute Care setting required BSN and/or Bachelors degree in health related field preferred

　　Licensure, Certifications, and Clearances:

　　CPR required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire.

　　Basic Life Support (BLS) OR Cardiopulmonary Resuscitation (CPR)

　　Registered Nurse (RN)

　　UPMC is an Equal Opportunity Employer/Disability/Veteran