Telephonic Care Manager (RN) - Medicare Case Management

UPMC is a world-renowned, nonprofit health care provider and insurer committed to delivering exceptional, people-centered care and community services. Headquartered in Pittsburgh and affiliated with the University of Pittsburgh Schools of the Health Sciences, UPMC is shaping the future of health through clinical and technological innovation, research, and education. Dedicated to advancing the well-being of our diverse communities, we provide nearly $2 billion annually in community benefits, more than any other health system in Pennsylvania. Our 100,000 employees — including more than 5,000 physicians — care for patients across more than 40 hospitals and 800 outpatient sites in Pennsylvania, New York, and Maryland, as well as overseas. UPMC Insurance Services covers more than 4 million members, providing the highest-quality care at the most affordable price. To learn more, visit UPMC.com.

Are you an experienced nurse looking for the next challenge in your career? Do you have knowledge of care management or care coordination? The UPMC Health Plan is hiring a full-time Telephonic Care Manager to support our Medicare Case Management team. The Telephonic Care Manager is responsible for care coordination and health education for identified Health Plan members through telephonic 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 telephone or other electronic communication methods. This position is primarily remote; however, occasional travel to Downtown Pittsburgh will be required. This position will work standard daylight hours, Monday through Friday with occasional evenings required.

Present complex members for review 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. 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. Refers member 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 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. Coordinates and modifies the care plan with member, 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.