Professional Care Manager

About the role

The Care Manager coordinates the clinical and financial plan for patients, performing utilization management, resource management, discharge planning, and post‑acute care referrals and authorizations within a multidisciplinary team.

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.

Qualifications

• Graduate of an approved school of nursing; BSN preferred.
• Minimum two years of nursing experience; previous case management experience preferred.
• Knowledge of healthcare financial and payer issues, state/local/federal programs, and InterQual criteria preferred.
• Current licensure as a Registered Professional Nurse in the state of practice or in a state participating in the Nursing Licensure Compact.
• For employees practicing in Pennsylvania: UPMC Corporate Care Management Training Certificate of Completion (4‑6 weeks) required; UPMC‑approved Care Management certification preferred.
• Compliance with Act 33 / Act 34 / Act 73 with renewal as applicable.
• Out‑of‑state NLC license holders who change residency must obtain licensure in the new state within 60 days.