Nurse Clinical Care Coord-Allegheny County

UPMC•Pittsburgh, PA

3d•Hybrid

About The Position

UPMC Your Care is hiring a Full-Time Registered Nurse to service Downtown, East and/or South Allegheny County. The Nurse Clinical Care Coordinator is responsible for the delivery of nursing assessment and evaluation within recognized standards of nursing practice, care coordination, and health education with identified Health Plan members through face-to-face collaboration with members and their caregivers and providers. Identifies members' medical, behavioral, and social needs and barriers to care. Develops a comprehensive care plan that assists members to close gaps in preventive care, addresses barriers to care, and supports the member's self-management of chronic illness based on clinical standards of care. Collaborates and facilitates care with member’s primary care provider, UPMC Your Care Interdisciplinary Team, other departments, providers, community resources and caregivers to achieve desired member outcomes throughout the continuum of care. Members are followed by face-to-face interactions in their community, including the hospital, providers' offices, skilled nursing facility, home, or other health care facilities. Title and salary will be determined based upon education and nursing experience for Sr. Professional Care Manager within the Community and Ambulatory Services Division.

Requirements

Registered Nurse (RN) with an active PA license
CPR is required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire.
Valid driver’s license and reliable transportation (for home/community visits if applicable)
Automotive Insurance
Basic Life Support (BLS) OR Cardiopulmonary Resuscitation (CPR)
Driver's License
Registered Nurse (RN)
Act 33
Act 34
OAPSA
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

Bachelor of Science in Nursing (BSN) preferred
Case Management Certification (e.g., CCM, ACM, or RN-BC) is a plus
3+ years of clinical nursing experience Preferred (preferably in acute care, home health, care management, or primary care)
Strong knowledge of chronic disease management, including CHF, COPD, diabetes, hypertension, and CKD preferred
Familiarity with transitions of care processes and reducing hospital readmissions preferred
Experience working with socially complex or high-risk patient populations preferred
Case management certification or approved clinical certification preferred.

Responsibilities

Provides direct patient care, evaluates outcomes, and adjusts the nursing care process as indicated to ensure optimal member care.
Conducts comprehensive face-to-face assessments that include a clinical assessment and treatment, a review of the medical, functional, behavioral, pharmaceutical, and social needs of the member, including instrumental activities of daily living.
Review UPMC Health Plan data, EMR data, and documentation in the member's electronic health records as appropriate and identify gaps in care based on clinical standards of care.
Reviews the member's current medication profile: identifies issues related to medication adherence, and address with the member and providers as necessary.
Refer member for Comprehensive Medication Review as appropriate.
Successfully engages member to develop an individualized plan of care in collaboration with their primary care provider and the interdisciplinary team that promotes symptom management, goals of care/advanced directives, healthy lifestyles, closes gaps in care, reduces unnecessary ER utilization and hospital admissions/readmissions, and manages social determinants of health.
Coordinates and modifies the care plan with the member, caregivers, PCP, specialists, community resources, behavioral health, and other health plan and system departments as appropriate.
Completes all necessary documentation, which may include visit assessments, plan of treatment, verbal orders, and care coordination activities, accurately and promptly in the electronic documentation system while in the member’s home and within regulatory standards.
Data syncs (transmits) information the same day.
Leads the interdisciplinary team and assigns other interdisciplinary team members as appropriate to assist in the appropriate delivery of services as ordered on the plan of care to the member.
Engages members in palliative or hospice care, and/ or other education or self-management programs as appropriate.
Provide members with appropriate education materials or resources to enhance their knowledge and skills related to health or lifestyle management.
Assists the member with the transition of care between health care facilities, including the sharing of clinical information and the plan of care.
Contact members with gaps in preventive health care services and assist them in scheduling required screening or diagnostic tests with their providers.
Assist the member to schedule a follow-up appointment after emergency room visits or hospitalizations, and/or schedule a UPMC Your Care visit.
Plan standards and identify trends and opportunities for improvement based on information obtained from interaction with members and providers.
Presents or contributes to complex case reviews by the interdisciplinary team, summarizing clinical and social history, current medications, geriatric syndromes, healthcare resource utilization, and case management interventions.
Updates the plan of care following review and communicates recommendations to the member, caregivers, and providers.
Supervises and/or collaborates with a team of support staff assigned to the geographic region of the care manager.
Attends and participates in face-to-face case conferences, team meetings, and other work-related meetings.
Exercises independent judgement in matters concerning emergent and non-emergent member care needs and communicates with the physician/advanced practice provider as appropriate.
Demonstrates knowledge and understanding of the UPMC standard of care delivery and proficiency in all aspects of member care, including complex and/or specialized care.