Clinical Care Manager (RN) - Shadyside

Clinical Care Manager

Are you looking for an opportunity to use your nursing background in outpatient, home health, or case management? Do you have an interest in health insurance, but thrive on working in a medical office setting with face-to-face interaction with the members you are caring for? UPMC Health Plan is hiring a full-time Clinical Care Manager to support our partnership with various physician practices.

This role will support practices in Shadyside. The position will work standard daylight hours, Monday through Friday with no evenings, weekends, or holidays!

The Clinical Care Manager is responsible for 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 other medical management staff, other departments, providers, community resources and caregivers to provide additional support. Members are followed by face to face interactions in their community including the hospital, providers' offices, home, and other health care facilities. Title and salary will be determined based upon education and nursing experience for Sr. Professional Care Manager within the Insurance Services Division. Responsibilities:

1. Assist member with transition of care between health care facilities including sharing of clinical information and the plan of care.
2. Document all activities in the Health Plan's care management tracking system following Health
3. Successfully engage member to develop an individualized plan of care in collaboration with their primary care provider that promotes healthy lifestyles, closes gaps in care, and reduces unnecessary ER utilization and hospital readmissions. Coordinate and modify the care plan with member, caregivers, PCP, specialists, community resources, behavioral health contractor, and other health plan and system departments as appropriate.
4. Review member's current medication profile; identify issues related to medication adherence, and address with the member and providers as necessary. Refer member for Comprehensive Medication Review as appropriate.
5. Refer members to appropriate case management, health management, or lifestyle programs based on assessment data. Engage members in the Beating the Blues or other education or self-management programs. Provide members with appropriate education materials or resources to enhance their knowledge and skills related to health or lifestyle management.
6. Contact members with gaps in preventive health care services and assist them to schedule required screening or diagnostic tests with their providers. Assist member to schedule a follow up appointment after emergency room visits or hospitalizations.
7. Plan standards and identify trends and opportunities for improvement based on information obtained from interaction with members and providers.
8. Present or contribute to complex case reviews by the interdisciplinary team summarizing clinical and social history, healthcare resource utilization, case management interventions. Update the plan of care following review and communicate recommendations to the member and providers.
9. Conduct comprehensive face to face assessments that include the medical, behavioral, pharmacy, and social needs of the member. Review UPMC Health Plan data and documentation in the member electronic health records as appropriate and identify gaps in care based on clinical standards of care.

Minimum of 2 years of experience in a clinical setting and case management nursing required. Minimum 1 year of health insurance experience required. BSN preferred. 1 year of experience in clinical, utilization management, home care, discharge planning, and/or case management preferred. Excellent organizational skills. High level of oral and written communication skills. Computer proficiency required Licensure, Certifications, and Clearances: Case management certification or approved clinical certification required (or must be obtained within 2 years of hire to remain in role) CPR required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire Automotive Insurance Basic Life Support (BLS) OR Cardiopulmonary Resuscitation (CPR) Certified Case Manager (CCM) Driver's License Registered Nurse (RN) Act 33 with renewal Act 34 with renewal Act 73 FBI Clearance with renewal 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. UPMC is an Equal Opportunity Employer/Disability/Veteran