Job Description

Job Title: Case Manager (RN) - Quality Improvement
Job ID: 691951
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Department: Quality Improvement
Location: 600 Grant St, Pittsburgh PA 15219


Are you an experienced nurse looking for a unique case management opportunity? We may have the perfect position for you! UPMC Health Plan is hiring a regular full-time Case Manager to support the Quality Improvement department. In this role, you will work with a small, close-knit team to identify Health Plan members with gaps in care.

The Quality Case Manager ensures continuity and coordination of care for Health Plan members with care coordination, health care education, and self management needs. The Care Manager identifies member barriers and whole person needs' of the members including medical, behavioral, pharmaceutical and social needs. Develops a comprehensive care plan that includes prevention, member self management education, and clinical standards of care. Coordinates with other medical management staff, other departments, providers, members, and care givers to provide additional support to the members.

  • Based on assessment of members needs and environment, indentify applicable barriers, problems, goals, and interventions that will address those needs and improve or maintain the health status of the member.
  • 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.
  • Contact potential case management members to determine if there is a need for case management intervention based on the UPMC Health Plan protocols and timeframes established for the applicable clinical program.
  • Follow-up with the member according to established clinical program protocols and timeframes to monitor their status, evaluate the effectiveness of the individualized plan of care, and identify new needs. Modify the individualized plan of care or case status based on the status of the member.
  • Perform duties and responsibilities in accordance with the philosophy and standards of the UPMC Health Plan, including conveying courtesy, respect, enthusiasm, and a positive attitude through contacts with staff, health plan members, peers, and external contacts.
  • Provide case management according to program descriptions including member education, follow up on a timely basis and eliminating barriers to care.
  • Successfully engage member to develop an individualized plan of care to promote healthy lifestyles, close gaps in care, reduce unnecessary ER utilization and hospital readmissions. Develop and coordinate the individualized plan of care with the member, member's family, providers and community agencies as applicable. Involve other staff to support the individualized plan of care based on identified needs of the member


  • Five years of experience in clinical, utilization management, home care, discharge planning, and/or case management required.
  • Three years of experience in a managed care environment preferred.
  • Ability to interact with physicians and other health care professionals in a professional manner required. 
  • Computer proficiency required. 
  • Excellent verbal and written communication and interpersonal skills required

Licensure, Certifications, and Clearances:
  • Valid Pennsylvania RN licensure required.
  • Bachelor's degree in nursing preferred.
  • Case Manager certification preferred.
  • RN license in other states as assigned.

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $26.64 to $44.88

Union Position: No

At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!


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