Clinical Care Manager (RN) - Oakland/Shadyside

About the role

UPMC Health Plan is hiring a full-time Clinical Care Manager to support our partnership with various physician practices. This role will support locations in the Oakland and Shadyside area of Pittsburgh. The position will work standard daylight hours, Monday through Friday with no evenings, weekends, or holidays.

Responsibilities

• Conduct comprehensive face-to-face assessments that include medical, behavioral, pharmacy, and social needs of the member.
• Assist members with transition of care between healthcare facilities including sharing of clinical information and the plan of care.
• Develop an individualized plan of care in collaboration with the member’s 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.
• 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.
• 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.
• 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.
• Identify trends and opportunities for improvement based on information obtained from interaction with members and providers.
• 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.
• 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.

Requirements

• Minimum of 2 years of experience in a clinical setting and case management nursing required.
• 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.

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.