DEPARTMENT: Clinical Services
POSITION SUMMARY:
Performs assigned duties and clinical functions in accordance with Upper Peninsula Health Plan (UPHP) plans, policies, and procedures, all state and federal accrediting and regulatory standards and Blue Cross Blue Shield of Michigan (BCBSM) Physician Group Incentive Program (PGIP) requirements.
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, as well as National Committee for Quality Assurance (NCQA), BCBSM PGIP, and all regulatory standards.
3. Assists in the development and maintenance of policies and procedures related to PGIP and other assigned programs in accordance with program, regulatory, and accrediting standards.
4. Prepares reports and educational materials as required and presents reports and educational information via webinars and forums.
5. Engages with practices to onboard and participate with BCBSM PGIP initiatives. Assists in the development of practice incentive design, as requested.
6. Conducts onsite assessments with participating practices’ at least annually to determine BCBSM PGIP initiative progress; this includes scheduling, travel arrangements, onsite assessment, and post assessment follow-up.
7. Demonstrates knowledge of all BCBSM PGIP requirements; Centers for Medicare and Medicaid Services (CMS) standards; all applicable NCQA standards; and Healthcare Effectiveness Data and Information Set (HEDIS) measures as they relate to clinical functions and respective programs; assumes responsibility for specific NCQA and BCBSM standards as assigned.
8. Participates in departmental and interdepartmental process improvements; recommends improvements in clinical processes as opportunities are identified.
9. Participates in internal and external workgroups, collaboratives, and specialized trainings as required by BCBSM and/or UPHP.
10. Serves as backup to other team members in their respective areas in demonstrated times of excessive workload and/or benefit time.
11. Attends and participates in BCBSM PGIP and UPHP organizational, departmental, and clinical program meetings as required.
12. Assures required licensure continuing education requirements are fulfilled on an annual basis.
13. Maintains confidentiality of client data.
14. Performs other related duties as assigned or requested.
POSITION QUALIFICATIONS:
Education:
Minimum:
Licensed practical nurse or associate degree in nursing or health care-related area; three (3) years
of clinical or health related experience will be considered in lieu of certification or degree
Preferred:
Bachelor’s degree in nursing, health education, or health-related area
Requirement:
If nursing degree, licensed in state of Michigan
Experience:
Minimum:
Two (2) years of clinical or health-related experience
Preferred:
Three (3) to five (5) years of clinical experience; understanding of clinical quality data and
performance improvement.
Required Skills:
Keyboarding proficiency and working knowledge of MS Office programs Word, Excel, and PowerPoint
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, Canva, Monday.com, and Webinar platforms (i.e., Microsoft Teams)
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 travel is required
Subject to many interruptions
Exposure to situations requiring exceptional interpersonal skills or high productivity
Frequently subjected to irregular hours
