Telephonic Care Manager- Community HealthChoices

UPMC Health Plan has an exciting opportunity for a Telephonic Care Manager position in the Community Healthchoices department.  This is a full time position working Monday through Friday 8:00 a.m. to 5:00 p.m. with flexibility.  This is a remote position, but due to offices located in Pennsylvania for onsite needs of technology or operational reasons candidates are expected to reside 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.

Responsibilities:

• Warm transfers member for IEB referrals as appropriate.

• Successful manipulation of Excel Spreadsheets and accurate Excel spreadsheet data management is required.

• 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.

• 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.

Prefer experienced: 

• Positive, teachable Telephonic Care Manager to maintain NFI caseload while primary focus is Clinical Review Team duties such as managing Adverse Determinations and Redetermination Reviews.  

• OPS 29 Reporting duties would also be carried out monthly as scheduled. 

• Responsible for timely management of NFI caseload activities such as tasking, referrals, and collaboration with other stakeholders.  

• Ability to work as a unified team member and HCBS liaison in addition to listening and carrying out instructions via Supervisor directives and Workflows/Job Aids independently.  

• Excellent understanding of Medicaid, Medicare, and LTSS waiver programs strongly preferred.