Clinical Coordinator - Accreditation Program Lead

DATE: January 9, 2024 POSITION: Clinical Coordinator – Accreditation Program Lead DEPARTMENT: Clinical Services POSITION SUMMARY: 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; supports the clinical services manager and the director of the department by acting as the lead for the respective clinical program.
ESSENTIAL DUTIES AND RESPONSIBILITIES: 1.
Follows established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.
2.
Performs all assigned tasks in accordance with UPHP plans, policies and procedures, and National Committee for Quality Assurance (NCQA) and regulatory standards 3.
Works with the leadership teams to ensure compliance with NCQA and Centers for Medicare and Medicaid Services (CMS) standards and guidelines.
4.
Provides oversight of administrative duties related to accreditation program processes and procedures.
5.
Responsible for coordination and ongoing monitoring of Quality Assurance Improvement (QAI) utilization management (UM) program objectives in accordance with accreditation and contractual requirements.
6.
Assures program portion of clinical services work plan is completed on an accurate and timely basis.
7.
Collaborates with the clinical services manager to update policies and procedures in accordance with accrediting standards and to determine the impact of regulatory changes.
8.
Prepares reports, audits, and analyzes data.
9.
Demonstrates knowledge of all clinical Michigan Department of Community Health (MDCH), CMS, Department of Insurance and Financial Services (DIFS), and applicable NCQA standards.
10.
Assists in cross-departmental coordination of accreditation processes, including both new and existing NCQA accreditation requirements as set forth by NCQA, Michigan Department of Health and Human Services (MDHHS), and CMS and Healthcare Effectiveness Data and Information Set (HEDIS®) measures as they relate to clinical functions and respective programs.
11.
Leads program process improvement workgroups and participates in interdepartmental process improvement activities; identifies new areas for process improvement based on recurring provider or member issues and recommends improvements to program and clinical processes.
12.
Responsible for the education of new UPHP staff regarding respective program processes and procedures.
13.
Serves as backup to other program staff in their respective areas in demonstrated times of excessive workload and/or benefit time.
14.
Attends and participates in organizational, departmental, and clinical program meetings as required.
15.
Maintains confidentiality of client data.
16.
Performs other related duties as assigned or requested.
POSITION QUALIFICATIONS: Education: Minimum: Licensed practical nurse, associate degree in nursing, or bachelor’s degree in healthcare related area.
Preferred: Bachelor’s degree in nursing, health education, or healthcare related area Requirement: If nursing degree, licensed in state of Michigan Experience: Minimum: Three (3) years of clinical experience or health-related quality experience; three (3) years of appropriate UPHP clinical coordinator experience; or two (2) years of direct NCQA Accreditation experience Preferred: Five (5) or more years of healthcare quality or audit experience; experience reviewing statistical data Required Skills: Keyboarding proficiency and working knowledge of MS Office programs (Word, Excel, and PowerPoint).
Excellent oral/written communication.
Excellent organizational abilities including meeting deadlines, managing multiple tasks effectively, and goal setting.
Ability to handle high-pressure situations.
Ability to work independently.
Flexibility; ability to adjust to changing requirements and priorities.
Ability to interpret and analyze healthcare quality data.
Desired Skills: Working knowledge of MS Office Access Leadership skills, including advising, coaching, conflict resolution, decision making, and delegation.
Experience with health care auditing/accreditation processes.
Experience with medical record review.
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.
Physical Requirements: [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 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 Working Conditions: Works in office conditions, but occasional travel may be required Subject to many interruptions Exposure to situations requiring exceptional interpersonal skills or high productivity Occasionally subjected to irregular hours