Community Based Clinical Coordinator – Care Manager

This is a fully remote position, open to applicants in Michigan.

📋 Description

• Executes designated clinical functions in alignment with Upper Peninsula Health Plan (UPHP) plans, policies, and procedures, as well as all relevant state and federal accrediting and regulatory standards.

• Conducts care management responsibilities to evaluate, plan, and coordinate all facets of medical and supportive services across the care continuum for selected members to enhance quality and cost-effective care.

• Adheres to established UPHP policies and procedures, objectives, safety protocols, and maintains sensitivity towards confidential information.

• Completes all assigned duties in accordance with UPHP plans, policies, and procedures; National Committee for Quality Assurance (NCQA) standards; and all regulatory obligations.

• Conducts necessary and frequent in-person visits with members in various care environments, including their homes and nursing facilities.

• Acts as a single point of contact for members; collects essential health histories and monitors members’ home settings, access to community services, and social needs related to health and behavior.

• Evaluates members’ current health conditions, resource usage, previous and ongoing treatment plans and services, prognosis, and both short and long-term goals, along with available treatment and provider options.

• Creates care plans based on assessments, detailing specific objectives, goals, and interventions tailored to meet members' needs.

• Oversees the delivery of services and referrals made to community-based organizations, medical care, and other resources to support the members' overall care management strategy.

• Utilizes critical thinking skills to address members' inquiries and unmet physical, health-related social needs, as well as behavioral health care requirements.

• Fulfills the role of a member advocate and collaborates with support teams, medical offices, equipment suppliers, home health agencies, hospital care teams, and others to ensure effective discharge planning, care coordination, and management of acute and long-term care services.

• Identifies associated risk management and quality issues and reports these situations to the relevant authority.

• Engages in departmental and interdepartmental process enhancements, suggesting improvements when opportunities arise, and aids in the creation and upkeep of care management policies and procedures in line with regulatory and accrediting standards.

• Demonstrates understanding of all clinical standards set by the Michigan Department of Health and Human Services (MDHHS), Centers for Medicare and Medicaid Services (CMS), and Department of Insurance and Financial Services (DIFS); all applicable NCQA Utilization Management (UM), Quality Improvement (QI), Care Management, and Member's Rights and Responsibility (RR) standards; and the Healthcare Effectiveness Data and Information Set (HEDIS®) measures as they pertain to clinical functions and the care management program; assumes responsibility for specific NCQA standards as assigned.

• Provides backup support to other team members during peak workloads and/or when they are on leave.

• Participates in organizational, departmental, Interdisciplinary Care Team (ICT) meetings, and other clinical program meetings as required.

• Ensures confidentiality of client information.

• Performs other related duties as assigned or requested.

⛳️ Requirements

• 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.

• 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 with statistical data analysis.

• Valid Driver’s License with proof of insurance.

• Proficiency in keyboarding and a working knowledge of MS Office programs, specifically Word and Excel.

🏝️ Benefits

• Competitive pay.

• Comprehensive health insurance.

• A 401(k) plan.

• Student Loan Repayment Programs.

• Tuition Reimbursement opportunities.

• 12 paid holidays.

• No mandatory overtime, nights, or weekend hours.