Clinical Coordinator - UM
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AI Summary
Processes prior authorization requests for medical and long-term supports and services while ensuring compliance with regulatory standards. Maintains and updates utilization management criteria and performs clinical auditing of member records.
DATE: June 23, 2026
POSITION: Clinical Coordinator—Utilization Management
DEPARTMENT: Clinical Services
RATE: $28.26 per hour, with potential for additional compensation based on qualifications.
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.
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; National Committee for Quality Assurance (NCQA) standards; and all regulatory requirements.
3. 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.
4. Annually reviews and updates UPHP developed utilization management (UM) criteria for UPHP Clinical Advisory - Utilization Management Committee (CA-UMC) review and approval.
5. Reviews inpatient readmissions utilizing approved criteria to ensure the readmission was appropriately billed to UPHP.
6. Reviews member records for departmental and interdepartmental auditing and monitoring purposes as assigned.
7. Assists in the development and maintenance of policies and procedures related to utilization management in accordance with regulatory requirements and accrediting standards.
8. Prepares reports as required.
9. 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.
10. Participates in departmental and interdepartmental process improvements; recommends improvements in clinical processes as opportunities are identified.
11. Serves as backup to other team members in their respective areas in demonstrated times of excessive workload and/or benefit time.
12. Attends and participates in organizational, departmental, and clinical program meetings as required.
13. Assures required licensure continuing education requirements are fulfilled on an annual basis.
14. Maintains confidentiality of client data.
15. Performs other related duties as assigned or requested.
POSITION QUALIFICATIONS:
Education:
Minimum:
Licensed registered nurse
Preferred:
Bachelor’s degree in nursing
Requirement:
Licensed in state of Michigan
Experience:
Minimum:
Two (2) years of clinical or health-related experience
Preferred:
Three (3) to five (5) years of clinical managed care experience; experience in utilization management;
experience in utilization review; experience reviewing statistical data
Required Skills:
Keyboarding proficiency and working knowledge of MS Office programs Word and Excel
Excellent human relation and oral/written communication
Excellent organizational and prioritization abilities
Desired Skills:
Ability to interpret and analyze data
Working knowledge of MS Office 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.
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 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
Working Conditions:
Position available onsite (in Marquette, Michigan), fully remote, or hybrid with a remote work option up to three (3) days per week
Occasional travel may be required
Subject to many interruptions
Exposure to situations requiring exceptional interpersonal skills or high productivity
Occasionally subjected to irregular hours
Remote Work Requirements:
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
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