You will be working Monday – Friday daylight shifts no on call for these roles. Possible weekend and evening rotations might be in the future state of the program. You will be doing a combination of types of visiting including telemedicine, in home visits, calls, etc. The office is located at Harbor Gardens, 1650 Metropolitan Street, 15233.
The Nurse Clinical Care Coordinator is responsible for delivery of nursing assessment and evaluation within recognized standards of nursing practice, care coordination and health education with identified Health Plan members through face-to-face 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 member’s primary care provider, UPMC Your Care Interdisciplinary Team, other departments, providers, community resources and caregivers to achieve desired member outcomes throughout the continuum of care. Members are followed by face-to-face interactions in their community including the hospital, providers’ offices, skilled nursing facility, home, or other health care facilities. Title and salary will be determined based upon education and nursing experience for Sr. Professional Care Manager within the Community and Ambulatory Services Division.
Responsibilities:
Provides direct patient care, evaluates outcomes, and adjusts nursing care process as indicated to ensure optimal member care. Conducts comprehensive face to face assessments that include a clinical assessment and treatment, a review of the medical, functional, behavioral, pharmaceutical, and social needs of the member, including instrumental activities of daily living. Review UPMC Health Plan data and EMR data and documentation in the member electronic health records as appropriate and identify gaps in care based on clinical standards of care. Reviews 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. Successfully engages member to develop an individualized plan of care in collaboration with their primary care provider and the interdisciplinary team that promotes symptom management, goals of care/advanced directives, healthy lifestyles, closes gaps in care, and reduces unnecessary ER utilization and hospital admissions/readmissions, and manages social determinants of health. Coordinates and modify the care plan with member, caregivers, PCP, specialists, community resources, behavioral health, and other health plan and system departments as appropriate. Completes all necessary documentation which may include visit assessments, plan of treatment, verbal orders, and care coordination activities accurately and promptly in electronic documentation system while in the member’s home and within regulatory standards. Data syncs (transmits) information same day. Leads the interdisciplinary team and assigns other interdisciplinary team members as appropriate to assist in the appropriate delivery of services as ordered on the plan of care to the member. Engages members in palliative or hospice care, and/ or other education or self-management programs as appropriate. Provide members with appropriate education materials or resources to enhance their knowledge and skills related to health or lifestyle management. Assists member with transition of care between health care facilities including sharing of clinical information and the plan of care. Contacts members with gaps in preventive health care services and assist them to schedule required screening or diagnostic tests with their providers. Assist member to schedule a follow up appointment after emergency room visits or hospitalizations, and/or schedule a UPMC Your Care visit. Plans standards and identify trends and opportunities for improvement based on information obtained from interaction with members and providers. Presents or contributes to complex case reviews by the interdisciplinary team summarizing clinical and social history, current medications, geriatric syndromes, healthcare resource utilization, case management interventions. Updates the plan of care following review and communicates recommendations to the member, caregivers, and providers. Supervises and/or collaborates with a team of support staff assigned to the geographic region of the care manager. Attends and participates in face-to-face case conferences, team meetings, and other work-related meetings. Exercises independent judgement in matters concerning emergent and non-emergent member care needs and communicates with the physician/advanced practice provider as appropriate. Demonstrates knowledge and understanding of the UPMC standard of care delivery and proficiency in all aspects of member care, to include complex and/or specialized care.