Upper Peninsula Health Plan

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. 

1. Follows established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.

 

2. 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. 

 

3. 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.

 

4. Monitors delivery of services and referrals made to community-based organizations, medical care, and other services to support the members’ overall care management plan.

 

5. Applies critical thinking skills to address member questions and unmet physical, health related social needs, and behavioral health care needs.

 

6. 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.

 

7. Identifies related risk management and quality concerns and reports these scenarios to the appropriate body.

 

8. Performs all assigned tasks in accordance with UPHP plans, policies, and procedures; National Committee for Quality Assurance (NCQA) standards; and all regulatory requirements.

 

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.

Licensed registered nurse with an associate degree in nursing  

Licensed registered nurse with a bachelor of science degree in nursing  

Licensed in state of Michigan

 

Two (2) years of clinical or health-related experience as a licensed registered nurse

Two (2) years of clinical managed care experience, two (2) years of experience in utilization review, 

or five (5) years of clinical experience as a registered nurse; experience in care management; 

experience reviewing statistical data 

 

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

 

Ability to interpret and analyze data

Working knowledge of MS Office Access and PowerPoint

 

 

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

 

 

Works in office conditions, but frequent travel is required

Subject to many interruptions

Personal vehicle may be required for travel

Localized travel to conduct home visits in residential, community living, and/or nursing home settings

Exposure to situations requiring exceptional interpersonal skills or high productivity

Occasionally subjected to irregular hours