Complex Care Specialist

UPMC•Pittsburgh, PA

1d•Hybrid

About The Position

The Complex Care Specialist provides resources and guidance to the Clinical Care Coordination teams and their patients with needs that complicate the discharge plan and impact patient satisfaction, length of stay or other defined metrics. The specialist functions as a liaison to payors to create positive outcomes in the medical management and reimbursement of our patients. The specialist also functions as a liaison to external agencies and vendors who provide care in the post hospital setting. This role is hybrid coming into the Oakland office at least monthly.

Requirements

Diploma or associate degree in nursing and active Registered Nurse license. At least one year of experience in discharge planning/care coordination required.
OR
Bachelor's degree in social work or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of those being served required. Master's degree preferred. At least one year of experience required in discharge planning/care coordination.
Must possess knowledge in navigating communications with payer sources and programs.
Possess knowledge and understanding of regulatory guidelines.
Must be skilled in planning/organization, follow up/control, delegation.
Problem solving, self-development, organizational behaviors/competencies.
Must be able to read, understand, analyze, and interpret medical record documents.
Must possess the ability to apply principles of logic and critical thinking to a wide range of problems and to deal with a variety of abstract and concrete variables.
Demonstrate ability to function independently, taking initiative to be proactive and drive a discharge plan while working with a multi-disciplinary team.
Be able to lead care teams to develop and execute safe and efficient discharge plans.
Maintain knowledge about area resources and their capabilities and capacities as well as various types of service providers available
Demonstrate understanding of inpatient care setting operations.
Ability to manage multiple priorities in a fast-paced environment
Licensure: RN, LSW/LCSW, or education-appropriate license required
Licensed Certified Social Worker (LCSW) OR Licensed Social Worker (LSW) OR Registered Nurse (RN)
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.

Nice To Haves

Master's degree preferred.
Certification: CCM/ACM or other nursing or social work certification preferred

Responsibilities

Partner with the discharge plan manager on complex patient scenarios for discharge that includes: clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes.
Collaborates with the DPM to balance resources with patient preferences and goals of care; evaluate the potential impact of social determinants of health that may elevate the risk of a poor transition.
The specialist will provide consultation to the discharge plan managers when barriers are identified for discharge.
They will also review the electronic record to understand the level of care fit for discharge; identify barriers to transition to the new level of care and identify possible carve-out needs with specific payers as indicated.
The specialist will support the DPM in finding resolution to the barriers to discharge by identifying resources and making community connections as needed.
The specialist will help to develop alternative discharge plans and talk with payers when there is a payer issue; provide outreach to post-discharge resource leaders to advocate for the patient's needs and locate alternative resources.
Maintain knowledge about area resources and their capabilities and capacities as well as various types of service providers available.
Collaborate and act as a resource for appropriate arrangements for post-hospital care and support the team to avoid unnecessary delays in discharge for complex patients.
Engage in clear communication with the clinical care coordination team to develop individualized discharge plan of care.
Incorporate discipline-specific recommendations, test results, outstanding orders into the discharge plan and monitor.
Recognize and demonstrate shared accountability in the development of a discharge plan for complex patients with the clinical care coordination team and ensure optimal outcomes.
Align practice with the mission, vision, and values of the organization.
Adheres to ethical standards and codes of conduct of applicable professional organization and UPMC.
Maintain clinical knowledge of and ensures compliance with regulatory requirements.
Advocate on behalf of patient/family/caregivers for services, access and for the protection of the patient's health, well-being, safety, and rights.
Manage cost of care with the benefits of patient safety, clinical quality, risk and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes.
Embrace and incorporate innovation and technology to improve collaboration and patient outcomes.
Document care in the appropriate electronic platform.
Provide staff orientation and mentoring as appropriate.