Role Description Are you a registered nurse with a background in utilization management? UPMC Health Plan is looking for you! We are hiring a full-time Utilization Management Care Manager to support the Utilization Management Clinical Operations Department. This position will predominantly work from home, standard daylight hours, Monday through Friday. The Utilization Management (UM) Care Manager is responsible for utilization review of health plan services and assessment of member's barriers to care. Interacts daily with facility clinicians, physicians, and UPMC Health Plan care managers and Medical Directors as part of the member treatment team. Provides guidance and assistance to providers and members to ensure that health care needs are met through the delivery of covered services in the most appropriate setting and cost-effective manner. - Obtain documentation to support requested level of care within the defined health plan regulatory timeframes and provide verbal and/or written notification to providers as applicable. - Consult with health plan medical director to discuss medical necessity for requested service. - Document all activities in the Health Plan's care management tracking system following Health Plan and internal department standards and identify trends and opportunities for improvement based on information obtained from interaction with members and providers. - Review and document clinical information from health care providers including clinical history, home environment, support system, available caregiver, cognitive and psychological status. - Conduct clinical reviews for authorization requests using established criteria including Interqual, Mahalik, and health plan policy and procedures for inpatient, outpatient, Durable Medical Equipment (DME), Behavioral Health, and Private Duty Nursing. - Participate in health plan interdisciplinary team conferences and collaborative case reviews to discuss complex cases and determine appropriate discharge plan or level of service. - Consult with health plan medical director on an as needed basis to discuss medical necessity for requested service. - Work closely with peers and other departments to determine discharge needs including necessary referrals to health plan care management for short or long term interventions. - Maintain communication with health care providers regarding health plan determinations. - Identify potential quality of care concerns and never events and refers to health plan quality management department. Qualifications - Minimum of 2 years of experience in a clinical and/or case management nursing required. - Minimum of 1-year work-related experience in Utilization Management required. - Experience with prior authorizations preferred. - PA RN license preferred. - Strong organizational, task prioritization and problem-solving skills. - Ability to construct grammatically correct reviews using standard medical terminology. - Computer proficiency required. Requirements - Case management certification or approved clinical certification preferred. - Registered Nurse (RN). PA licensure preferred. - Act 34. - Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. - Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state. Company Description UPMC is an Equal Opportunity Employer/Disability/Veteran.

Requisition Number: 2358802 Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. Network Contract Managers develop the provider network, yielding a geographically competitive, broad access, stable network that achieves objectives for unit cost performance and trend management, and produces an affordable and predictable product for customers and business partners. They evaluate and negotiate contracts in compliance with company contract templates, reimbursement structure standards, and other key process controls. Responsibilities also include establishing and maintaining solid business relationships and ensuring the network composition includes an appropriate distribution of provider specialties. If you are located in the tri-state area (NY, CT, NJ), you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities: - Manage unit cost budgets, target setting, performance reporting and associated financial models with High Profile Providers (large hospitals and health systems) - Guide development of geographically competitive, broad access, stable networks that achieve objectives for unit cost performance and trend management - Evaluate and negotiate contracts, reimbursement methodologies, and rates in compliance with company templates, reimbursement structure standards, and other key process controls - Manage unit cost, target parameters, performance reporting and associated financial models - Ensure that network composition includes an appropriate distribution of provider and specialties and overall recruitment and contracting to ensure network adequacy - Collaborate with internal contacts to implement regulatory requirements impacting provider contracts (state specific changes to state published rates, coding, new services, and requirements) - Maintain existing network contracts and any contracting events that occur during the term of the agreement while generating savings opportunities for affordability initiatives - Coordinate high profile negotiations, build and nature trusted relationships with providers and internal state holders - Engage facility and hospital providers and any internal resources to resolve issues related to contract administration - Provide explanations and information for others on difficult issues In this role, you will need to be able to thrive in a demanding, intense, challenging environment. In addition, you will be driving some complex negotiations while striving to ensure accuracy. You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: - 2+ years of experience in a network management-related role, such as contracting or provider services - Experience utilizing financial models and / or financial analysis for the purpose of negotiating rates with providers or meeting other business needs - Experience in performing network adequacy analysis - Knowledge of Medicaid and/or Medicare - Intermediate level of knowledge of claims processing systems and guidelines - Proven excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others - Driver's License and access to reliable transportation Preferred Qualifications: - Experience in Payment Appendix and fee schedule development - Behavioral Health provider experience - Facility/Hospital contracting experience - Knowledge of the Northeast market - Proven sound people skills, establishing rapport and working well with others - Proven sound customer service skills *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

• Owns client proposal development in collaboration with Commercial Sales Account Executives • Coordinates cross-functionally within Commercial Sales and with various Advarra SMEs in the development of proposals, vendor assessments, and other requested documents • Ensures compliance with requirements specified in RFPs and vendor assessment requests • Customizes, proofreads, edits, and ensures accuracy of the final proposal/questionnaire document • Completes all required forms and obtains all necessary signatures • Manages the coordination and timeline for completion of the RFP or questionnaire • Maintains their project documentation including proposal/questionnaire, attachments, communications, etc. • Maintains and updates proposal boilerplate, current corporate information, location profiles, resumes, bios, customer references and templates as needed

• Own customer contract processes and renewals. • Collaborate with sales representatives and customer success managers. • Establish cooperative working relationships with customers. • Lead forecasting discussions and pipeline reviews. • Engage multiple customers via phone calls daily.