Practice Based Care Manager, OP - Medical Art Center Primary Care

UPMC•Cumberland, MD

About The Position

UPMC’s Medical Art Center Primary Care is seeking a dedicated Practice Based Care Manager to support physicians in coordinating care for highly complex patients within the practice. In this role, you will partner closely with patients, families, providers, and community resources to develop individualized care plans, reduce barriers to care, and improve health outcomes. The ideal candidate is relationship-driven, highly organized, and skilled in navigating clinical, behavioral health, and social needs across the continuum of care. This position plays a key role in chronic care management, care transitions, and ongoing patient follow-up to promote quality, continuity, and patient-centered care. This full-time position will work Monday through Friday between the hours of 8:00am and 4:30pm. No holidays, evenings or weekends are required. This role will require home visits or meeting patients in other settings in the community so a willingness to travel and work at multiple locations is required.

Requirements

Graduate of approved school of nursing.
Two (2) years of nursing experience in an outpatient setting required
Ability to interact with physicians and other health care professionals in a professional manner required.
Must have an understanding of health care disparity issues and have the ability to interact with members from diverse backgrounds in a culturally appropriate manner.
Excellent verbal and written communication and interpersonal skills required.
Ability to use independent judgment and compassion when carrying out tasks.
Must be flexible with work schedule and may have to travel between offices as needed to see patients and or huddle with office staff.
Must have flexibility to work within the hours established by the practice and to adapt to a changing environment while still functioning effectively as part of a multidisciplinary team.
Registered Nurse (RN)
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

BSN or related Bachelor's degree preferred.
Experience in a physician practice and/or home health care highly desired.
Previous case management experience preferred.

Responsibilities

Once patient is ready to leave the program, facilitates transition back to the Primary Care Doctor of the patients.
Meets face to face with patients and family members initially and as needed to build a relationship, assess the patient's medical, behavioral health and social needs, identify barriers
Works very closely with and maintains open communications with the Primary Care Physician of the extensive care program for direction and collaboration related to patient needs and assessment.
Documents all assessments, interventions and plans of care completely and accurately into the electronic health record.
Assess patient's appropriateness for enrollment into the Chronic Care Management program in terms of meeting criteria, approval by PCP, and patient and families willingness to participate.
In collaboration with the team, develops and coordinates an individualized plan of care with the patient, patient's family, health insurance plan, providers and community agencies as applicable.
Involves additional providers as needed to support the individualized plan of care based on identified needs of the patient and family and/or care giver. Plan designed to promote health, close gaps in care, decrease unplanned care.
Actively participates in planned team meetings to monitor patient's status, evaluate the effectiveness of the individualized plan of care, and identify new needs and strategize for next steps.
Maintains availability to patient and /or care giver as needed by phone or visit.
Rotates call by phone according to systems developed in the practice for Chronic Care Management program.
Follows up with patient and/or care givers regularly to assess patient's medical status or compliance to plan or or to offer assistance as needed.