UPMC Health Plan’s Community HealthChoices team is looking for a Telephonic Care Manager to join the team! Community HealthChoices (CHC) is Pennsylvania’s managed care long-term services and supports (LTSS) program serving seniors and individuals with physical disabilities in the Commonwealth who are covered by Medicare and Medicaid.
This is a remote position and does not require any travel. This position will primarily be responsible for assisting Service Coordination with Nursing Facility Transitions and the Complex Case Unit.
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.

• 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.
• Minimum of 2 years of experience in a clinical setting and case management nursing required.
• Experience with Service Coordination in the community and nursing facility settings strongly preferred
• Proficiency with PASRR services and Money Follows the Person strongly preferred
• Experience with leading interdisciplinary teams to facilitate and support discharge planning and managing transitions of care strongly preferred
• Excellent understanding of Medicaid, Medicare, and LTSS waiver programs strongly preferred
• BSN preferred.
• Ability to interact with physicians and other health care professionals in a professional manner required.
• Excellent verbal and written communication and interpersonal skills required.
• Computer proficiency required.
• 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. Most cable and fiber optic providers can meet the requirement. Private, secure designated workspace required in the home office setting or the ability to work from a designated UPMC office location daily.Licensure, Certifications, and Clearances:
• Case management certification or approved clinical certification preferred
• Registered Nurse (RN)
• Act 34
• 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.