POSITION SUMMARY:
Performs assigned clinical functions in accordance with Upper Peninsula Health Plan (UPHP) plans, policies, and procedures, and all state and federal accrediting and regulatory standards. Performs care management duties to assess, plan, and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Follows established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.
2. Performs all assigned tasks in accordance with UPHP plans, policies, and procedures; National Committee for Quality Assurance (NCQA) standards; and all regulatory requirements.
3. 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.
4. 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.
5. Monitors delivery of services and referrals made to community-based organizations, medical care, and other services to support the members' overall care management plan.
6. Applies critical thinking skills to address member questions and unmet physical, health related social needs, and behavioral health care needs.
7. 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.
8. Identifies related risk management and quality concerns and reports these scenarios to the appropriate body.
9. 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.
10. 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.
11. Serves as backup to other team members in their respective areas in demonstrated times of excessive workload and/or benefit time.
12. Attends and participates in organizational, departmental, Interdisciplinary Care Team (ICT) meetings, and other clinical program meetings as required.
13. Maintains confidentiality of client data.
14. Performs other related duties as assigned or requested.
POSITION QUALIFICATIONS:
Education:
Minimum:
Licensed registered nurse
Preferred:
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
Requirement:
Licensed in state of Michigan
Experience:
Minimum:
Two (2) years of clinical or health-related experience as a licensed registered nurse or social worker
Preferred:
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
Other Requirements:
Valid Driver's License with proof of insurance
Working vehicle
Required Skills:
Keyboarding proficiency and working knowledge of MS Office programs Word and Excel
Excellent human relation and oral/written communication
Excellent organizational and prioritization abilities
Desired Skills:
Ability to interpret and analyze data
Working knowledge of MS Office Access and PowerPoint
The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria.
Physical Requirements:
[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:
Ability to access departmental files
Ability to enter and access information from a computer
Ability to access all areas of the UPHP offices
Moderate physical effort (lift/carry up to 25 pounds)
Occasionally lifts supplies/equipment
Occasional reaching, stooping, bending, kneeling, crouching
Prolonged periods of sitting
Occasional prolonged standing
Manual dexterity and mobility
Working Conditions:
Works in office conditions, but frequent travel is required
Subject to many interruptions
Exposure to situations requiring exceptional interpersonal skills or high productivity
Occasionally subjected to irregular hours
Remote Work Requirements:
Initial on-site/in-person onboarding and training for a minimum of ten (10) consecutive business days at UPHP's headquarters in Marquette, MI (stipend provided)
Periodic travel to UPHP's headquarters for regular training including bi-monthly all staff meetings.
Private home office required; computer and phone hardware provided
Personal vehicle required for travel; mileage reimbursement provided at GSA rate
Localized travel to conduct home visits in residential, community living, and/or nursing home settings
