Join UPMC’s new 24/7 Home First Center, an innovative care model designed to provide patients with seamless support and coordination across the healthcare continuum.

As a Telephonic Care Manager, you will play a critical role in helping patients navigate transitions in care following hospitalization, emergency department visits, observation stays, and other significant healthcare events. Through comprehensive assessments, individualized care planning, care coordination, patient advocacy, and connection to community and healthcare resources, you will help ensure patients receive the right care, at the right time, in the right setting

As part of the Integrated Delivery & Finance System (IDFS), this role supports both discharge planning and transitional care management, providing a unique opportunity to influence patient outcomes across the full continuum of care. Working closely with patients, families, physicians, hospitals, post-acute providers, community organizations, and interdisciplinary care teams, you will help improve continuity of care, address barriers that impact health outcomes, support safe and successful transitions between care settings, and promote positive patient experiences throughout the healthcare journey.

This is a primarily remote position supporting a 24/7 operation. Team members work rotating 12-hour shifts, including days, nights, weekends, and holidays, with schedules consisting of 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. coverage. While the role is primarily remote, occasional on-site attendance may be required for training, department meetings, team collaboration, and other business needs.

What You’ll Do:

Comprehensive Assessment & Care Planning

• Conduct comprehensive assessments to identify medical, psychosocial, financial, environmental, and support needs, including social determinants of health that may impact recovery and successful transitions of care.

• Develop, implement, and continuously update individualized care plans that align with patient goals, clinical needs, and available resources.

• Identify barriers to care and proactively develop solutions that support patient safety, independence, and positive health outcomes.

Care Coordination & Transition Management

• Coordinate transitions across hospitals, emergency departments, observation units, skilled nursing facilities, rehabilitation centers, home health agencies, physician offices, and community-based services.

• Partner with physicians, nurses, social workers, therapists, pharmacists, and other interdisciplinary team members to facilitate safe discharges and seamless transitions of care.

• Arrange and coordinate follow-up appointments, referrals, transportation, durable medical equipment, and other services necessary to support recovery and continuity of care.

• Monitor patient progress following significant healthcare events and address barriers that may impact treatment adherence or follow-up care.

Community Resource Coordination & Patient Advocacy

• Connect patients and caregivers with healthcare services, community organizations, post-acute resources, payer care management programs, and other support services that promote recovery and long-term wellness.

• Advocate for patients throughout the care transition process, ensuring individual goals, preferences, and cultural considerations are reflected in care planning whenever appropriate.

• Educate and support patients and families as they navigate complex healthcare systems, empowering them to make informed decisions about their care and available resources.

Resource Stewardship & Quality Outcomes

• Promote effective utilization of healthcare resources while maintaining a focus on quality, patient safety, and positive outcomes.

• Identify and resolve barriers that impact successful care transitions, helping to reduce avoidable delays in care, unnecessary utilization, and potential readmissions.

• Maintain accurate documentation and utilize care management technology and tools to support communication, coordination, and outcome tracking.

• Participate in quality improvement initiatives focused on patient experience, transitions of care, and care coordination outcomes.

Professional Practice & Team Collaboration

• Collaborate as an active member of interdisciplinary care teams and contribute to a culture of patient-centered care.

• Maintain compliance with regulatory, accreditation, and organizational standards while staying current on best practices in care management and transitions of care.

• Support team success through participation in training, onboarding, mentoring, and continuous improvement efforts.