Clinical Care Manager (RN) - Allegheny County

Responsibilities

• Aid members during transitions of care between health facilities, sharing clinical information and care plans.
• Develop personalized care plans in collaboration with primary care providers to promote healthy lifestyles and reduce unnecessary ER visits and hospital readmissions.
• Coordinate and adjust care plans with members, caregivers, specialists, community resources, and other health plan and system departments.
• Review and address medication adherence issues with members and providers.
• Refer members to Comprehensive Medication Reviews and appropriate case management, health management, or lifestyle programs.
• Engage members in education or self-management programs like Beating the Blues.
• Provide members with educational materials and resources to improve their health or lifestyle management.
• Contact members with gaps in preventive health care services and assist them in scheduling required screenings or diagnostic tests.
• Afford members with follow-up appointments after emergency room visits or hospitalizations.
• Plan and identify areas for improvement based on interactions with members and providers.
• Conduct comprehensive face-to-face assessments covering medical, behavioral, pharmacy, and social needs.
• Analyze UPMC Health Plan data and documentation to identify gaps in care based on clinical standards.

Requirements

• Minimum of 2 years of experience in a clinical setting and case management nursing.
• Bachelor of Science in Nursing (BSN) preferred.
• Minimum 1 year of health insurance experience required.
• 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.

Qualifications

• Case management certification or approved clinical certification required (or must be obtained within 2 years of hire).
• CPR required based on AHA standards.
• Certified Case Manager (CCM) certification preferred.
• Driver’s License.
• Registered Nurse (RN) license.
• Licenses and clearances as per UPMC policies, including Act 33, Act 34, Act 73, FBI clearance, and automotive insurance.