RN Care Coordinator: Chronic Care & Home Visits

UPMC; Pittsburgh (Allegheny County); On-site; USD 75,000 - 95,000; Full time

Job summary

UPMC Your Care is hiring a Full-Time Registered Nurse to service Downtown, East and/or South Allegheny County. The Nurse Clinical Care Coordinator delivers nursing assessments and care coordination to health plan members through face-to-face interactions in the community and medical facilities.

The role emphasizes identifying medical, behavioral, and social needs, developing comprehensive care plans, and collaborating with primary care providers and the interdisciplinary team to improve outcomes

Qualifications

• Active PA RN license required.
• BSN preferred.
• Case management certification a plus.
• 3+ years clinical nursing experience preferred.
• Strong knowledge of chronic disease management (CHF, COPD, diabetes, hypertension, CKD).
• Familiarity with transitions of care and reducing readmissions.
• Experience with socially complex or high-risk populations preferred.
• Valid driver's license and reliable transportation for home/community visits.

Responsibilities

• Provide direct patient care and evaluate outcomes; adjust nursing care as needed.
• Conduct comprehensive face-to-face assessments in home, hospital, or community settings.
• Collaborate with PCP and interdisciplinary team; develop individualized care plans.
• Coordinate and document care plans; ensure timely data sync in EMR.

Skills

Active PA RN license

BSN preferred

Case management certification

3+ years clinical nursing

Chronic disease management knowledge

Transitions of care experience

Social determinants of health

Valid driver's license

Education

BSN preferred

Job description

UPMC Your Care is hiring a Full-Time Registered Nurse to service Downtown, East and/or South Allegheny County. The Nurse Clinical Care Coordinator delivers nursing assessments and care coordination to health plan members through face-to-face interactions in the community and medical facilities.

The role emphasizes identifying medical, behavioral, and social needs, developing comprehensive care plans, and collaborating with primary care providers and the interdisciplinary team to improve outcomes