Health Plan Specialist

Pinnacle Health Systems•Pittsburgh, PA

42d•Onsite

About The Position

UPMC Health Plan is hiring a licensed individual to function as a Health Plan Specialist to work onsite at UPMC Shadyside. This role will work standard daylight hours, Monday through Friday, onsite at Shadyside Hospital. The Health Plan Specialist will act as a connector, building a bridge for UPMC Health Plan members between hospital services and Health Plan and community resources. They will support the Discharge Plan Managers, identifying members who might have higher needs and benefit from Health Plan resources. Additionally, they will help to link Your Care Program eligible members to a Your Care representative for enrollment. Individuals hired into this role will be hired into the appropriate title as either a Mobile Professional Care Manager, Sr Mobile Care Manager, or Clinical Care Manager based on experience and qualifications.

Requirements

For Sr Mobile Care Manager Master's degree in social work/human service field OR licensed RN (BSN preferred) OR Paramedic/EMT with 8-10 year of experience
6 years of experience in medical social work, home care, discharge planning, and case management required.
For Mobile Care Manager Pennsylvania Licensure in health or human services field and master's degree OR licensed RN (BSN preferred) OR Paramedic/EMT with 6-8 year of experience.
3 years of experience in behavioral, clinical, utilization management, home care, discharge planning, and/or case management required
For Clinical Care Manager Minimum of 2 years of experience in a clinical setting and case management nursing required.
Minimum 1 year of health insurance experience required.
Case management certification or approved clinical certification required (or must be obtained within 2 years of hire to remain in role)
Registered Nurse (RN)
LSW, CSW, LCSW LPC, Licensed Marriage Family Therapist, Paramedic, EMT, RN or Psychologist required
Valid driver's license required
Proof of current automobile insurance
Valid CPR certification required
Current Act 33/34
Clearance required
Current Act 73 FBI required.

Responsibilities

Demonstrates role model behavior for the team.
Conducts member assessments, identifying behavioral, clinical, social, and environmental concerns and needs, and provides unique expertise as the UPMC Health Plan liaison.
Coordinates care and services across the continuum of care with case management, physicians, pharmacy, behavioral health, and other providers or health plan departments as appropriate.
Provides leadership and expertise regarding the resources available to UPMC Health Plan members through community and government agencies.
Makes member referrals and is the UPMC Health Plan liaison to other UPMC Health Plan medical case managers and team members.
Facilitates the comprehensive integration of behavioral health services with existing physical health services for members with significant co-morbidity. Independently identifies and analyzes barriers to care; develops specific integrated plan of care in collaboration with the member, family, providers, and UPMC Health Plan staff.
Assesses members' knowledge of their clinical conditions and the need for further education; independently provides education concerning complex physical health and behavioral health conditions.
Ensures that cases are managed and documentation is within established timeframes in accordance with departmental standards.
Participates and facilities professional development project and activities as assigned in senior role.
Participates in case conferences, interagency and provider treatment planning and departmental meetings.
Conducts face-to-face member assessments by visiting the member in the member's community, place of residence, or facility.
Conducts on-site hospital or facility coordination for discharge planning with facility staff if needed.
Acts as a UPMC Health Plan liaison for members with facility admissions; actively networks with UPMC Health Plan high-risk and acute care managers.
Coordinates with members' providers and Practice-Based Care Managers to ensure follow-up and coordination of care.
Performs duties and responsibilities in accordance with the philosophy and standards of the UPMC Health Plan, including conveying courtesy, respect, enthusiasm, integrity, innovation, and a positive attitude through contacts with staff, health plan members, peers, and external contacts.