Nurse Clinical Care Coord - CAS, UPMC Your Care

UPMC Your Care is hiring a full-time Nurse Clinical Care Coordinator

This position will primarily cover the North Hills. The ideal candidate will live in or near the North Hills or can reliably and sustainably cover the North Hills  territory 

Hours:  Monday-Friday 8:00 am-4:30 pm/5:00 pm 

Purpose:
The Nurse Clinical Care Coordinator is responsible for the 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 the 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, including clinical assessment and treatment, and reviews the member's medical, functional, behavioral, pharmaceutical, and social needs, including instrumental activities of daily living. Review UPMC Health Plan data and EMR data and documentation in the member's 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 modifies 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 the electronic documentation system while in the member’s home and within regulatory standards. Data syncs (transmits) information the 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. Provides members with appropriate education materials or resources to enhance their knowledge and skills related to health or lifestyle management. Assists members 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 assists them to schedule required screening or diagnostic tests with their providers. Assists members to schedule a follow-up appointment after emergency room visits or hospitalizations, and/or schedule a UPMC Your Care visit. Plans standards and identifies 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, and 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 judgment 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.