Telephonic Care Manager (RN) - Adult Care Management

UPMC Health Plan is hiring a full-time Telephonic Care Manager to support our Medical Management department. This position is based in Downtown Pittsburgh but will predominantly work remotely, with standard daylight hours Monday through Friday.

About the role

The Telephonic Care Manager is responsible for care coordination and health education for identified adult Health Plan members through telephonic collaboration with members, their caregivers, and providers. You will identify members' medical, behavioral, and social needs and barriers to care, then develop a comprehensive care plan to close gaps in preventive care, address barriers, and support self-management of chronic illness based on clinical standards.

You will collaborate with medical management staff, other departments, providers, community resources, and caregivers to provide additional support. Members are followed by telephone or other electronic communication methods.

Responsibilities

• Present complex members for review by the interdisciplinary team, summarizing clinical and social history, healthcare resource utilization, and case management interventions.
• Update the plan of care following review and communicate recommendations to the member and providers.
• Contact members with gaps in preventive health care services and assist them to schedule required screening or diagnostic tests with their providers.
• Review member's current medication profile; identify issues related to medication adherence, and address with the member and providers as necessary.
• Refer members for Comprehensive Medication Review as appropriate.
• Conduct comprehensive assessments that include the medical, behavioral, pharmacy, and social needs of the member.
• Review UPMC Health Plan data for services the member has received and identify gaps in care based on clinical standards of care.
• Refer members to appropriate health plan programs based on assessment data.
• Engage members in education or self-management programs.
• Provide members with appropriate education materials or resources to enhance their knowledge and skills related to physical health, emotional health, or lifestyle management.
• Successfully engage members 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 members, caregivers, PCP, specialists, community resources, behavioral health contractor, and other health plan and system departments as appropriate.
• Document all activities in the Health Plan's care management tracking system following Health Plan standards and identify trends and opportunities for improvement based on information obtained from interaction with members and providers.
• Conduct member outreach in response to assist with member issues or concerns or facilitate specific population health goals.
• Seek input from clinical leadership to resolve issues or concerns.

Requirements

• Minimum of 2 years of experience in a clinical setting and case management nursing.
• BSN preferred.
• Ability to interact with physicians and other health care professionals in a professional manner.
• Excellent verbal and written communication and interpersonal skills.
• Computer proficiency.
• Meet minimum internet system/service and speed/latency requirements as set forth by UPMC. Equipment must be connected directly or hard-wired to the internet modem/router with an ethernet cable.
• Private, secure designated workspace required in the home office setting or the ability to work from a designated UPMC office location daily.

Qualifications

• Registered Nurse (RN) licensure, current in the state where the facility is located or a multistate license issued by a participating Nursing Licensure Compact (NLC) state.
• Case management certification or approved clinical certification preferred.
• Act 34 clearance required.