Precert Care Manager (Evening Shift)

UPMC Community Care Behavioral Health is hiring a full-time Precert Care Manager. This role will work Monday - Friday 3:30 pm - midnight with rotating weekends and holidays. Occasional overnight coverage may be needed at times. This role works fully remote and must reside within 2 hours of a CCBH office location. Candidate should reside within Pennsylvania or the tri-state area.

A Precert Care Manager for the 24 hour precert team must be able and willing to work daylight, evening, and night shift positions that also rotate weekend and holiday coverage. A Precert Care Manager is responsible for documenting and reviewing clinical information and making authorization determinations for adult and child/adolescent members being referred to acute and non-ambulatory mental health and substance use disorder levels of care for all Community Care contracts. The Care Manager will also be responsible for crisis management and referring members to appropriate services based on triage assessment. The Care Manager executes these responsibilities consistent with the applicable Community Care Policies and Procedures. A care manager represents the organization to providers, member groups and families, and participates in the overall administration of clinical operations as warranted. A care manager is expected to bring a level of clinical leadership to the care management department. In addition, a care manager may serve as the care management lead for other members of his/her team.

Responsibilities:

• Coordinates, reviews, and maintains daily logs for reporting purposes and for weekly preparation and analysis of trending reports to address member incidents, provider deficiencies, and quality of care concerns.
• Independently problem solves based on advanced-level knowledge of the service delivery system, clinical treatment, diversion resources, and the provider network for adult and child/adolescent members for behavioral health and SUD providers from the requested region, member services policies, members' rights and responsibilities, and the operating practices of the organization
• Responds to deadlines and has work completed on or before deadline 95% of the time.
• Identify need for and facilitate linkages for members and families between primary care and behavioral health providers and other social service or provider agencies to develop and coordinate service plans.
• Maintains an understanding of behavioral health benefits and remains current on covered benefits, limitations, exclusions, and policies and procedures, in regards to services. Is able to provide members, providers and other stakeholders with accurate information concerning benefits and coverage.
• Demonstrates excellent clinical, written and oral communication skills.
• Utilizes supervision with team coordinator and clinical manager regularly.
• Assumes responsibility for completion of acute and non-ambulatory precerts and application of appropriate medical necessity guidelines. Precerts include adult and child/adolescent members from all Community Care being admitted to mental health and substance use disorder services, as well as afterhours/weekend completion of precerts for UPMC Health Plan Commercial and SNP lines of business.
• Assist with moving members to in network facilities or coordinating with appropriate Community Care contracts regarding approval for out of network service utilization.
• Consults with appropriate physician advisors as needed for case collaboration and care planning.
• Develops specific clinical interventions and coordinates with the assigned Community Care contract and care management team for members who do not maintain regular contact with their behavioral health provider as recommended contributing to frequent crises, recidivism, and interfering with maximum benefit from available care.
• Participates in professional development activities to further clinical skills and knowledge. Works as part of a team providing clinical expertise and knowledge to member services and other care management staff.
• Demonstrates advanced level of computer operation with electronic medical record systems and Microsoft Outlook, Word, and Excel Programs, as well as advanced typing proficiency.
• Receives and responds appropriately to complex calls, including Afterhours/Weekend Employee Assistance Program calls, triage calls, and provider or member complaints. Ensures accurate, thorough, and correct documentation of these calls.