Job Description

Are you an experienced Pediatric nurse with care management experience? We have a unique opportunity that may be a perfect fit for you! 

UPMC Health Plan is hiring a full-time Pediatric Telephonic Care Manager to support the Medical Management Medicaid team. This position will be predominantly working from home and will primarily work standard daylight hours, Monday through Friday. The team is based out of downtown Pittsburgh, but team members may reside anywhere in Pennsylvania.

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. Title and salary will be determined based upon education and nursing experience for Sr. Professional Care Manager within the Insurance Services Division.

Responsibilities:

• 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.

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