Clinical Care Manager (RN) - Aspinwall & Natrona Heights

UPMC•Pittsburgh, PA

12h•Onsite

About The Position

UPMC Health Plan is hiring a full-time Clinical Care Manager to support a partnership with various physician practices in Aspinwall, Harmar, and Natrona Heights. This role offers an opportunity to use a nursing background in outpatient, home health, or case management, with an interest in health insurance while working in a medical office setting with face-to-face interaction with members. The position involves standard daylight hours, Monday through Friday, with no evenings, weekends, or holidays. The Clinical Care Manager is responsible for care coordination and health education with identified Health Plan members through face-to-face collaboration with members, their caregivers, and providers. Key responsibilities include identifying members' medical, behavioral, and social needs and barriers to care, and developing a comprehensive care plan to close gaps in preventive care, address barriers, and support self-management of chronic illness based on clinical standards. The role requires collaboration and facilitation of care with other medical management staff, departments, providers, community resources, and caregivers. Members are followed through face-to-face interactions in various community settings, including hospitals, providers' offices, homes, and other health care facilities. The title and salary will be determined based on education and nursing experience for a Sr. Professional Care Manager within the Insurance Services Division.

Requirements

Minimum of 2 years of experience in a clinical setting and case management nursing required.
Minimum 1 year of health insurance experience required.
Excellent organizational skills
High level of oral and written communication skills
Computer proficiency required
Case management certification or approved clinical certification required (or must be obtained within 2 years of hire to remain in role)
CPR required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire
Automotive Insurance
Basic Life Support (BLS) OR Cardiopulmonary Resuscitation (CPR)
Certified Case Manager (CCM)
Driver's License
Registered Nurse (RN)
Act 33 with renewal
Act 34 with renewal
Act 73 FBI Clearance with renewal
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.

Nice To Haves

1 year of experience in clinical, utilization management, home care, discharge planning, and/or case management preferred

Responsibilities

Assist member with transition of care between health care facilities including sharing of clinical information and the plan of care.
Document all activities in the Health Plan's care management tracking system following Health Plan standards and identify trends and opportunities for improvement based on information obtained from interaction with members and providers.
Successfully engage member to develop an individualized plan of care in collaboration with their primary care provider that promotes healthy lifestyles, closes gaps in care, and reduces unnecessary ER utilization and hospital readmissions.
Coordinate and modify the care plan with member, caregivers, PCP, specialists, community resources, behavioral health contractor, and other health plan and system departments as appropriate.
Review member's current medication profile; identify issues related to medication adherence, and address with the member and providers as necessary.
Refer member for Comprehensive Medication Review as appropriate.
Refer members to appropriate case management, health management, or lifestyle programs based on assessment data.
Engage members in the Beating the Blues or other education or self management programs.
Provide members with appropriate education materials or resources to enhance their knowledge and skills related to health or lifestyle management.
Contact members with gaps in preventive health care services and assist them to schedule required screening or diagnostic tests with their providers.
Assist member to schedule a follow up appointment after emergency room visits or hospitalizations.
Present or contribute to complex case reviews by the interdisciplinary team summarizing clinical and social history, healthcare resource utilization, case management interventions.
Update the plan of care following review and communicate recommendations to the member and providers.
Conduct comprehensive face to face assessments that include the medical, behavioral, pharmacy, and social needs of the member.
Review UPMC Health Plan data and documentation in the member electronic health records as appropriate and identify gaps in care based on clinical standards of care.