Clinical Coordinator - UM

Upper Peninsula Health Plan•Marquette, MI

1d•Hybrid

About The Position

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. Processes prior authorizations requests for medical and long term supports and services (LTSS) and provides written notification to the member and provider (if applicable) of the decision within specified timeframes. Annually reviews and updates UPHP developed utilization management (UM) criteria for UPHP Clinical Advisory - Utilization Management Committee (CA-UMC) review and approval. Reviews inpatient readmissions utilizing approved criteria to ensure the readmission was appropriately billed to UPHP. Reviews member records for departmental and interdepartmental auditing and monitoring purposes as assigned. Assists in the development and maintenance of policies and procedures related to utilization management in accordance with regulatory requirements and accrediting standards. Prepares reports as required. Demonstrates knowledge of the Michigan Department of Health and Human Services (MDHHS), Centers for Medicare and Medicaid Services (CMS) and Department of Insurance and Financial Services (DIFS) standards and all applicable NCQA UM standards as they relate to the UM program; assumes responsibility for specific NCQA standards as assigned. Participates in departmental and interdepartmental process improvements; recommends improvements in clinical processes as opportunities are identified. 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, and clinical program meetings as required. Assures required licensure continuing education requirements are fulfilled on an annual basis. Maintains confidentiality of client data. Performs other related duties as assigned or requested.

Requirements

Licensed registered nurse
Licensed in state of Michigan
Two (2) years of clinical or health-related experience
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 enter and access information from a computer
Ability to access all areas of the UPHP offices
Must reside in the Upper Peninsula of Michigan

Nice To Haves

Bachelor’s degree in nursing
Three (3) to five (5) years of clinical managed care experience
Experience in utilization management
Experience in utilization review
Experience reviewing statistical data
Ability to interpret and analyze data
Working knowledge of MS Office PowerPoint

Responsibilities

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.
Processes prior authorizations requests for medical and long term supports and services (LTSS) and provides written notification to the member and provider (if applicable) of the decision within specified timeframes.
Annually reviews and updates UPHP developed utilization management (UM) criteria for UPHP Clinical Advisory - Utilization Management Committee (CA-UMC) review and approval.
Reviews inpatient readmissions utilizing approved criteria to ensure the readmission was appropriately billed to UPHP.
Reviews member records for departmental and interdepartmental auditing and monitoring purposes as assigned.
Assists in the development and maintenance of policies and procedures related to utilization management in accordance with regulatory requirements and accrediting standards.
Prepares reports as required.
Demonstrates knowledge of the Michigan Department of Health and Human Services (MDHHS), Centers for Medicare and Medicaid Services (CMS) and Department of Insurance and Financial Services (DIFS) standards and all applicable NCQA UM standards as they relate to the UM program; assumes responsibility for specific NCQA standards as assigned.
Participates in departmental and interdepartmental process improvements; recommends improvements in clinical processes as opportunities are identified.
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, and clinical program meetings as required.
Assures required licensure continuing education requirements are fulfilled on an annual basis.
Maintains confidentiality of client data.
Performs other related duties as assigned or requested.