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UPMC Your Care is Hiring a Full-Time Registered Nurse for a Nurse Clinical Care Coordinator Position.

This position travels to patients' homes in Allegheny County.

The Nurse Clinical Care Coordinator is responsible for delivering nursing assessments and evaluations within recognized standards of nursing practice, coordinating care, and providing health education to identified Health Plan members through face-to-face collaboration with members, their caregivers, and providers. Identifies members' medical, behavioral, and social needs, as well as 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 members' 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 on 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's electronic health records as appropriate and identify gaps in care based on clinical standards of care. Reviews member's current medication profile identifies issues related to medication adherence, and addresses with the member and providers as necessary. Refer the member for a 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, reduces unnecessary ER utilization and hospital admissions/readmissions, and manages social determinants of health. Coordinate and modify the care plan with the 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 same day. Leads the interdisciplinary team and assigns other interdisciplinary team members as appropriate to assist in the 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 members with transition of care between health care facilities, including sharing of clinical information and the plan of care. Contact members with gaps in preventive health care services and assist them in scheduling required screening or diagnostic tests with their providers. Assist members in scheduling 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 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.

+ Registered Nurse (RN) with an active PA License required

+ BSN Preferred

+ Case management nursing preferred.

+ Minimum 1 year of health insurance experience preferred.

+ 1 year of experience in clinical, utilization management, home care, discharge planning, and/or case management preferred.

+ Excellent organizational skills. High level of oral and written communication skills.

+ Excellent problem-solving skills, self-motivation, enthusiasm, and creativity required.

+ Computer proficiency required.

+ Valid Driver's License -required **Licensure, Certifications, and Clearances:** Case management certification or approved clinical certification preferred. CPR required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire.

+ Automotive Insurance

+ Basic Life Support (BLS) OR Cardiopulmonary Resuscitation (CPR)

+ Driver's License

+ Registered Nurse (RN)

+ Act 33

+ Act 34

+ OAPSA

*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.

UPMC is an Equal Opportunity Employer/Disability/Veteran