Health Care Manager (Pediatric)

UPMC Health Plan is hiring a full-time Pediatric Health Care Manager to support the Medical Management Medicaid team. This position will predominantly work from home and primarily work standard daylight hours, Monday through Friday with intermittent evening hours as needed. The team is based out of downtown Pittsburgh, but team members may reside anywhere in Pennsylvania. Occasional local travel may be required in the future.

The Health Manager ensures continuity and coordination of care for Health Plan members with chronic conditions and complex health needs.

Responsibilities:

• Provides members, providers, and other stakeholders with information concerning benefits and coverage, and provides accurate information to members and families.
• Monitors and evaluates effectiveness and outcome of treatment plans, restructures as necessary to provide optimal clinically appropriate services with a goal of maintenance in the community at the least restrictive level of care and maximal use of community supports and resources.
• Works with Member Services, Network Management and Quality Management staff to assure that systematic revisions to improve services are developed and implemented.
• Utilizes supervision by identifying and reporting to supervisor clinical, utilization and outcomes issues.
• Preserve confidentiality of the member.
• Develop and coordinate an individualized treatment plan with the member, member's family, and providers.
• Evaluate the effectiveness of the treatment plan and identify gaps in service. Make recommendations for changes when indicated.
• Assist in the development and review of training materials for staff, other UPMC Health Plan departments, and network providers.
• Independent problem solving based on sophisticated knowledge of in-plan services, the provider network, member services policies, members' rights and responsibilities, and the operating practices of the organization.
• Follow-up with the member according to established timeframes to monitor their care to assess whether quality care is being provided in an appropriate setting.
• Perform duties and responsibilities in accordance with the philosophy and standards of UPMC Health Plan, including conveying courtesy, respect, enthusiasm, and a positive attitude through contacts with staff, health plan members, peers, and external contacts.
• Identifies provider issues and recommendations for improvement.
• Contact potential case management members to determine if there is a need for case management intervention.
• Receives and responds to complex calls regarding requests for services or resolution of complex issues.
• Ability to propose and implement creative solutions to member problems and to achieve a high level of member satisfaction with services.
• Performs clinical reviews, service authorization and care coordination (or oversight and supervision) for all Health Plan members receiving services.
• Complete Annual Competencies including Ethics and Compliance, HIPAA, Safety, Fraud and Abuse and Confidentiality/Privacy and Security Awareness.
• Provide reports on case management cases or activities as requested.
• Perform in accordance with system-wide competencies/behaviors.
• Appropriate documentation in the care management documentation system including assessments, problems, goals and interventions.
• Assumes responsibility for health plan member's access to in-plan and/or supplemental services as medically indicated
• Interfaces with and refers members to community-based resources and other supportive services as appropriate.
• Maintains an understanding of behavioral health benefits and remains current on covered or in-plan services, benefit limitations, exclusions, and behavioral health management policies and procedures.
• Participate in integrated care team meetings in a cross-cultural environment to coordinate transitions of care, discharge planning, benefit coverage, conflict resolution and resource needs.
• Conduct comprehensive assessment of needs and coordination of care activities for individuals with primary diagnosis of alcohol or substance use addiction

• Master's degree in human service field plus licensure required or Licensed Pennsylvania RN with 6-8 years clinical experience required
  • Preference will be given to those with licensure in a human services field (LSW, LCSW or LPC)
• Five years of experience in clinical, care coordination, and/or case management required.
• Pediatric experience highly preferred.
• Three years of experience in a managed care environment preferred.
• General knowledge of best practices in health care, emphasizing work with special needs populations and in provider systems.
• Ability to interact with physicians and other health care professionals in a professional manner required.
• Computer proficiency required.
• Experience with Microsoft office products preferred.
• Excellent verbal and written communication and interpersonal skills required.
• Knowledge of community resources required.
  
  Licensure, Certifications, and Clearances:
  
• Registered Nurse (RN) or Social Services Licensure (LSW, LCSW, LPC)
• Licensure in other states as assigned
• Case management certification or approved clinical certification preferred
  
  
  UPMC is an Equal Opportunity Employer/Disability/Veteran