Purpose:
UPMC is currently hiring a full-time Telephonic Care Manager within its Insurance Services Division. This remote position focuses on providing care coordination and health education to identified Health Plan members through telephonic and electronic communication. The Care Manager collaborates with members, caregivers, and providers to assess medical, behavioral, and social needs, identify barriers to care, and develop comprehensive, clinically sound care plans. These plans aim to close gaps in preventive care, support chronic illness management, and empower members toward greater self-care. The role also involves close coordination with medical management staff, internal departments, community resources, and caregivers to ensure members receive holistic support. Ongoing engagement is maintained through regular follow-ups via phone or digital platforms. The standard schedule is Monday through Friday, 8:00 AM to 4:30 PM, with occasional evening coverage required from 4:30 PM to 6:00 PM. While the position is primarily remote, occasional in-office meetings may be required based on business needs

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.

• Minimum of 2 years of experience in a clinical setting and case management nursing required.
• BSN preferred. Ability to interact with physicians and other health care professionals in a professional manner required.
• Utilization management experience is a plus
• 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.