Clinical Care Manager (RN) - Penn Plum

UPMC•Pittsburgh, PA

14h

About The Position

UPMC Health Plan is hiring a full-time Clinical Care Manager to support its partnership with physician practices at Penn Plum Family Medicine. The role uses nursing experience in an outpatient, home health, or case management setting and combines face-to-face member interaction with health insurance-related care coordination. The position follows standard weekday daylight hours, Monday through Friday, with no evenings, weekends, or holidays. The Clinical Care Manager coordinates care and provides health education to identified Health Plan members through collaboration with members, caregivers, and providers. The role identifies medical, behavioral, and social needs and barriers to care, then develops comprehensive care plans that close preventive-care gaps, address barriers, and support chronic-illness self-management based on clinical standards. Members are followed through face-to-face interactions in community settings, including hospitals, provider offices, homes, and other health care facilities. The role also coordinates support with medical management staff, other departments, providers, community resources, and caregivers.

Requirements

At least 2 years of experience in a clinical setting and case management nursing.
At least 1 year of health insurance experience.
Excellent organizational skills.
Strong oral and written communication skills.
Computer proficiency.
Case management certification or an approved clinical certification; must be obtained within 2 years of hire to remain in the role if not already held.
CPR meeting AHA standards, including didactic and skills demonstration components, within 30 days of hire.
Automotive insurance.
Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR).
Driver's license.
Registered Nurse (RN) licensure in the state where the facility is located, or a multistate license issued by a participating Nursing Licensure Compact state where applicable. Employees on an out-of-state NLC license who change residency to the facility's state must apply for licensure there within 60 days.
Act 33 clearance with renewal.
Act 34 clearance with renewal.
Act 73 FBI clearance with renewal.

Nice To Haves

Bachelor of Science in Nursing (BSN).
One year of experience in clinical care, utilization management, home care, discharge planning, and/or case management.

Responsibilities

Assist members with transitions between health care facilities, including sharing clinical information and the plan of care.
Document activities in the Health Plan's care management tracking system.
Engage members to develop individualized plans of care in collaboration with primary care providers, promoting healthy lifestyles, closing care gaps, and reducing unnecessary emergency room utilization and hospital readmissions.
Coordinate and modify care plans with members, caregivers, primary care providers, specialists, community resources, behavioral health contractors, and other health plan and system departments as appropriate.
Review members' medication profiles, identify medication-adherence issues, and address them with members and providers as needed.
Refer members for Comprehensive Medication Review when appropriate.
Refer members to appropriate case management, health management, or lifestyle programs based on assessment data, and engage them in Beating the Blues or other education or self-management programs.
Provide members with education materials or resources to improve their knowledge and skills related to health or lifestyle management.
Contact members with preventive-care gaps and help them schedule required screening or diagnostic tests with providers.
Help members schedule follow-up appointments after emergency room visits or hospitalizations.
Apply plan standards and identify trends and improvement opportunities based on interactions with members and providers.
Present or contribute to interdisciplinary complex case reviews, summarizing clinical and social history, health care resource use, and case management interventions.
Update plans of care after review and communicate recommendations to members and providers.
Conduct comprehensive face-to-face assessments of members' medical, behavioral, pharmacy, and social needs.
Review UPMC Health Plan data and member electronic health record documentation as appropriate, identifying gaps in care based on clinical standards.