1. Follows established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.
2. Performs face-to-face visits with members in various care settings including acute care hospitals, outpatient clinics, Federally Qualified Health Centers, Rural Health Clinics, urgent care centers, rehabilitation facilities, nursing homes and other long term care facilities, home health settings, mobile clinics and provider offices. Face-to-face visits may also occur where a member lives, learns, works, plays or worships which may include but is not limited to the member’s home, school, workplace, faith based organization, community center, shelter, library or food pantry.
3. Provides Care Management services for multiple populations including but not limited to the following: disabled populations, pregnant and postpartum members, those members with chronic conditions, members enrolled in or eligible for Children’s Special Health Care Services (CSHCS), children in foster care, former foster care youth in Foster Care Transitional Medicaid, members within Cell and Gene Therapy (CGT), members engaged with mental or behavioral health services.
4. 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 through assessments.
5. 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 and maintains person centered care plans based upon assessment with specific objectives, goals, and interventions designed to meet member needs.
6. Monitors and coordinates delivery of services and referrals made to community-based organizations, medical care, behavioral health and other services to support the members’ overall care management plan.
7. Identifies barriers to care to help inform care management and care planning activities.
8. Applies critical thinking skills to address member questions and unmet physical, health related social needs, and behavioral health care needs.
9. 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 inpatient, outpatient, and community setting changes in condition.
10. Identifies related risk management and quality concerns and reports these scenarios to the appropriate body.
11. Performs all assigned tasks in accordance with UPHP plans, policies, and procedures; National Committee for Quality Assurance (NCQA) standards; and all regulatory requirements.
12. 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.
13. 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.
14. Serves as backup to other team members in their respective areas in demonstrated times of excessive workload and/or benefit time.
15. Attends and participates in organizational, departmental, or collaborative Interdisciplinary Care Team (ICT) meetings, and other clinical program meetings as required.
16. Maintains confidentiality of client data.
17. Follows all compliance, audit, policy and procedure requirements as it relates to Care Management, Care Coordination, documentation and charting specifications and timelines.
18. Performs other related duties as assigned or requested.
Licensed registered nurse
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 or health-related experience as a licensed registered nurse or social worker
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
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
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.
[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 enter and access information from a computer
Ability to access all areas of the UPHP offices
Occasionally lifts supplies/equipment
Prolonged periods of sitting
Manual dexterity
Position available onsite (in Marquette, Michigan), fully remote, or hybrid with a remote work option up to three (3) days per week
Works in office conditions, but frequent travel is required
Localized travel to conduct face-to-face visits in or at member’s preferred location
Subject to many interruptions
Exposure to situations requiring exceptional interpersonal skills or high productivity
Occasionally subjected to irregular hours
Must reside in the Upper Peninsula of Michigan
For remote team members, initial on-site/in-person onboarding and training for a minimum of ten (10) consecutive business days at UPHP’s headquarters in Marquette, Michigan (stipend provided)
Periodic travel to UPHP’s headquarters for regular training including all staff meetings
Private home office required; computer and phone hardware provided
Personal vehicle and proof of insurance required for business travel; mileage reimbursement provided at GSA rate
