Upper Peninsula Health Plan (UPHP)

Community Manager

• 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.
• Follows established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.
• Performs all assigned tasks in accordance with UPHP plans, policies, and procedures; National Committee for Quality Assurance (NCQA) standards; and all regulatory requirements.
• 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.
• 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.
• Monitors delivery of services and referrals made to community-based organizations, medical care, and other services to support the members’ overall care management plan.
• Applies critical thinking skills to address member questions and unmet physical, health related social needs, and behavioral health care needs.
• 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.
• Identifies related risk management and quality concerns and reports these scenarios to the appropriate body.
• 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.
• 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.
• Serves as backup to other team members in their respective areas in demonstrated times of excessive workload and/or benefit time.
• Attends and participates in organizational, departmental, Interdisciplinary Care Team (ICT) meetings, and other clinical program meetings as required.
• Maintains confidentiality of client data.
• Performs other related duties as assigned or requested.

Community Based Clinical Coordinator – Care Manager