UPMC Community Care Behavioral Health is hiring a Clinical Manager for the Care Management team in Erie, PA! This position will work standard business hours Monday – Friday and will work in a hybrid structure with time spent working in the office, travelling in the community and working remotely. 

The Clinical Manager is responsible for supervising the day-to-day operations of the Care Management Department. This responsibility includes daily supervision of the Care Management representatives to ensure that they respond promptly, effectively and courteously to inquiries from members, providers, prospective members and the general public. The Clinical Manager is responsible for the implementation of policies and procedures pertaining to Department functions and for monitoring Department operations consistent with those policies. The Manager also represents the organization to the general public and to member groups and participates in overall organizational management as warranted.

Responsibilities:

Recruit and train care management and other identified staff; supervise staff and conducts performance reviews as required by organization policies. Assist with coordinating information and making presentations to participating providers, state and federal agencies, community groups and other interested parties. Assist staff in aiding members, providers, prospective members and other departments with information concerning benefits and coverage. Review all requests for out of network requests. Work with Provider Relations and Quality Assurance staff to assure that systematic revisions to improve services are developed and implemented Maintain understanding of benefits and assures that department staff are current on covered benefits, limitations, exclusions, policies and procedures, computer screens and code definitions and maintains current awareness of Plan changes and developments. Supervise collection of information from members concerning problems with accessing services and/or benefits and uses that information to recommend modifications to plan policies and procedures which improve the flow of services to members. Work with staff, members and providers to customize benefits to best meet members’ needs within the policy parameters of the plan. Monitor performance of care managers and implements corrective action plans for administrative and clinical issues. Manage care management program, including compilation and analysis of trends. Develop care management interventions to address UM trends. Responsible for training providers, Members, and staff on issues related to quality, including complaints, grievances, quality monitoring, quality workplan, significant member incidents. Ensure outreach to appropriate priority populations. Ensure adequate electronic and paper documentation of clinical interventions. Supervise all clinical staff and ensures that all clinical reviews are consistent with medical necessity criteria. Monitor departmental performance against NCQA, URAC, DPW and other appropriate internal and external standards. Investigate claims and coverage inquiries from members and providers, gathers data and ensure appropriate follow-up of claim and service inquiries. Ensure adequate staff coverage for all shifts and ensures clinical supervision of after hours clinical care. Work with Customer Services Manager to coordinate activities between the two departments. Responsible for oversight of monitoring of complaints and grievances. Oversee complaint and grievance process from clinical perspective.