Clinical Care Manager (RN) - Health Plan Specialist - UPMC Shadyside

UPMC Health Plan is hiring a Clinical Care Manager to function as a Health Plan Specialist. This role will work standard daylight hours, Monday through Friday, onsite at Shadyside Hospital.

This role will act as a connector, building a bridge for UPMC Health Plan members between hospital services and Health Plan and community resources. They will also act as support to the Discharge Plan Managers, identifying members who might have higher needs and benefit from Health Plan resources. Additionally, they will help to connect Your Care Program eligible members to a Your Care representative for enrollment.

Responsibilities:

• Assist member with transition of care between health care facilities including sharing of clinical information and the plan of care.
• Document all activities in the Health Plan's care management tracking system following Health
• 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.
• 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 in scheduling required screening or diagnostic tests with their providers. Assist member in scheduling a follow-up appointment after emergency room visits or hospitalizations.
• Plan standards and 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.
• 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.

Qualifications:

• Minimum of 2 years of experience in a clinical setting and case management nursing required.
• 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)
• Driver's License
• Registered Nurse (RN)
• Act 33 with renewal
• Act 34 with renewal
• Act 73 FBI Clearance with renewal
• OAPSA

UPMC is an Equal Opportunity Employer/Disability/Veteran

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