Migliaccio & Rathod LLP is investigating whether UPMC Health Plan may have failed to pay overtime to certain utilization management nurses whose work involved applying predetermined clinical criteria and health-plan policies to authorization requests.
UPMC currently employs remote Utilization Management Care Managers who are registered nurses. A current UPMC posting states that these nurses conduct clinical reviews for authorization requests using established criteria including InterQual, Mahalik, and health-plan policies and procedures. The role also requires nurses to obtain supporting documentation within defined regulatory timeframes and consult with UPMC medical directors regarding medical necessity.
UPMC’s current materials therefore confirm a workflow centered on standardized criteria, defined review procedures, electronic documentation, and medical-director consultation.
Nurses May Have Been Required To:
- review inpatient, outpatient, behavioral-health, durable medical equipment, or other authorization requests;
- apply InterQual, Mahalik, Medicare, Medicaid, or UPMC criteria;
- obtain missing documentation from providers;
- work within defined regulatory and health-plan turnaround times;
- document each review in UPMC’s electronic care-management system;
- communicate with hospitals, physicians, and other providers;
- consult a medical director regarding medical necessity; and
- satisfy quality, timeliness, or productivity expectations.
UPMC’s current job description expressly says its UM Care Managers conduct authorization reviews using established criteria and consult health-plan medical directors regarding requested services.
Why Overtime May Be Owed
A nurse may be entitled to overtime even if the employer describes the position as clinical or professional.
Migliaccio & Rathod is investigating whether certain UPMC utilization-management nurses were paid on a salary basis and treated as overtime-exempt even though much of their work consisted of applying established criteria and company policies rather than independently making final medical-necessity decisions.
The distinction may be particularly important where a nurse was required to refer disputed, complex, or nonqualifying requests to a medical director.
Potential Claims May Include:
- unpaid overtime under the Fair Labor Standards Act;
- improper classification as overtime-exempt;
- unpaid wages under Pennsylvania or other applicable state laws;
- failure to accurately record hours worked; and
- liquidated or statutory damages.
Signs You May Be Affected:
- You worked for UPMC Health Plan as a UM Care Manager, Utilization Management Nurse, Utilization Review Nurse, Clinical Reviewer, or similar RN;
- you were paid a salary and did not receive overtime;
- you regularly worked more than 40 hours per week;
- you routinely used InterQual, Mahalik, CMS, or health-plan criteria to review cases;
- cases involving medical necessity were referred to or discussed with a medical director;
- you had productivity, timeliness, audit, or case-volume expectations; or
- you performed reviews or documentation before or after scheduled hours without additional pay.
If you have encountered these issues, we would like to hear from you. Please complete the contact form on this page, send us an email at [email protected], or give us a call.