Note: The job is a remote job and is open to candidates in USA. Upper Peninsula Health Plan (UPHP) is a healthcare organization seeking a Remote Community Based Clinical Coordinator - Care Manager. The role involves performing clinical functions and care management duties to assess, plan, and coordinate medical services for members, ensuring quality and cost-effective care across various settings.
Responsibilities
- Follows established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information
- Performs all assigned tasks in accordance with UPHP plans, policies, and procedures; National Committee for Quality Assurance (NCQA) standards; and all regulatory requirements
- Performs required, frequent in-person visits with members in various care settings including member homes and nursing facilities. Serves as a member’s single point of contact; gathers vital health history and monitors the member’s home environment, access to community-based services, and behavioral and health related social needs
- Assesses members’ current health status, resource utilization, past and present treatment plan and services, prognosis, short and long-term goals, and treatment and provider options. Develops plans of care based upon assessment with specific objectives, goals, and interventions designed to meet member needs
- Monitors delivery of services and referrals made to community-based organizations, medical care, and other services to support the members’ overall care management plan
- Applies critical thinking skills to address member questions and unmet physical, health related social needs, and behavioral health care needs
- Works as a member advocate and collaborates with support teams, medical care offices, medical equipment companies, home health agencies, hospital care teams, and other parties to ensure appropriate discharge plan, care plan, and coordination of acute care and long-term care services
- Identifies related risk management and quality concerns and reports these scenarios to the appropriate body
- Participates in departmental and interdepartmental process improvements, recommending improvements as opportunities are identified, and assists in the development and maintenance of policies and procedures related to care management in accordance with regulatory requirements and accrediting standards
- Demonstrates knowledge of all clinical Michigan Department of Health and Human Services (MDHHS), Centers for Medicare and Medicaid Services (CMS), and Department of Insurance and Financial Services (DIFS) standards; all applicable NCQA Utilization Management (UM), Quality Improvement (QI), Care Management, and Member's Rights and Responsibility (RR) standards; and Healthcare Effectiveness Data and Information Set (HEDIS®) measures as they relate to clinical functions and the care management program; assumes responsibility for specific NCQA standards as assigned
- Serves as backup to other team members in their respective areas in demonstrated times of excessive workload and/or benefit time
- Attends and participates in organizational, departmental, Interdisciplinary Care Team (ICT) meetings, and other clinical program meetings as required
- Maintains confidentiality of client data
- Performs other related duties as assigned or requested
Skills
- Licensed registered nurse
- Licensed in state of Michigan
- Two (2) years of clinical or health-related experience as a licensed registered nurse or social worker
- Valid Driver's License with proof of insurance
- Working vehicle
- Keyboarding proficiency and working knowledge of MS Office programs Word and Excel
- Excellent human relation and oral/written communication
- Excellent organizational and prioritization abilities
- Bachelor of science in nursing, limited licensed bachelor of social work, limited licensed master of social work, fully licensed bachelor of social work, or fully licensed master of social work
- Two (2) years of clinical managed care experience or five (5) years of clinical experience as a licensed registered nurse or social worker
- Experience in care management
- Experience reviewing statistical data
- Ability to interpret and analyze data
- Working knowledge of MS Office Access and PowerPoint
Benefits
- Stipend provided
- Computer and phone hardware provided
- Mileage reimbursement provided at GSA rate
Company Overview
Mission Statement The mission of UPHP is to be an innovative health plan managing the care of our members in the Upper Peninsula guiding them to quality, cost-effective care through our network of providers improving the overall health of the communities we serve. It was founded in 1998, and is headquartered in Marquette, Michigan, USA, with a workforce of 51-200 employees. Its website is https://www.uphp.com/.