Clinical Care Manager (RN) - Franklin/Oil City

UPMC•Franklin, PA

About The Position

UPMC Health Plan is hiring a full-time Clinical Care Manager to support its partnership with physician practices in the Franklin, Oil City, and Clarion area. The role works standard daylight hours, Monday through Friday, with no evenings, weekends, or holidays. The title and salary will be determined based on education and nursing experience for a Senior Professional Care Manager within the Insurance Services Division. The Clinical Care Manager provides care coordination and health education to identified Health Plan members through face-to-face collaboration with members, caregivers, and providers. The role identifies members’ medical, behavioral, and social needs and barriers to care, then develops comprehensive care plans to close preventive-care gaps, address barriers, and support chronic-illness self-management in accordance with clinical standards. The manager coordinates with medical management staff, other departments, providers, community resources, and caregivers. Face-to-face interactions may take place in the community, including hospitals, provider offices, members’ homes, and other health care facilities.

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; certification must be obtained within 2 years of hire to remain in the role.
CPR certification meeting AHA standards, including didactic instruction and a skills demonstration, within 30 days of hire.
Automotive insurance.
Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR).
Driver’s license.
Registered Nurse (RN) licensure.
Act 33 clearance with renewal.
Act 34 clearance with renewal.
Act 73 FBI clearance with renewal.
Current nursing licensure in the state where the facility is located, or a multistate license issued by a participating Nursing Licensure Compact state if the facility is in an NLC state. Employees working on an out-of-state NLC license who change residency to the facility’s state must apply for licensure there within 60 days.

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 of care 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 in developing individualized plans of care with their primary care providers to promote healthy lifestyles, close care gaps, and reduce unnecessary emergency-room utilization and hospital readmissions.
Coordinate and modify care plans with members, caregivers, primary care providers, specialists, community resources, the behavioral health contractor, and other health plan and system departments as appropriate.
Review members’ medication profiles, identify medication-adherence issues, address them with members and providers, and 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 members in Beating the Blues or other education and self-management programs.
Provide members with appropriate educational materials or resources to improve their health- and lifestyle-management knowledge and skills.
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-team complex case reviews, summarizing clinical and social history, health care resource use, and case-management interventions.
Update plans of care following reviews 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, and identify care gaps based on clinical standards.