UPMC Health Plan is hiring a full-time Coordinator, Quality Improvement. The team is based out of downtown Pittsburgh US Steel Tower, and this role will work in a hybrid structure with 3 days in the office per week - Monday, Wednesday, and Thursday. The ideal candidate will have prior experience in network management and/or member services.
This position is a valuable contributor to the Health Plan’s Quality Improvement Program, supporting various functions. This team member is one that enjoys the challenge of working independently but also has the ability to collaborate effectively across a wide variety of stakeholders. This position is heavily focused on assisting the Health Plan to achieve NCQA Health Plan Accreditation, LTSS Distinction, Health Outcomes Accreditation, and/or Community Focused Care Accreditation through effective project management skills.
This focus on Accreditation requires the incumbent to have a strong ability to collect, abstract, and analyze data for purposes of advancing quality improvement initiatives and achieving the Health Plan’s goals of excellence. Additionally, responsibilities may include, but are not limited to, delegation oversight, committee support, performance monitoring and assessment, and provider education and improvement activities.
Support and champion UPMC Health Plan safety initiatives as assigned. Perform duties and responsibilities in accordance with the philosophy, standards and policies and procedures of the UPMC Health System, including conveying courtesy, respect, enthusiasm and a positive attitude through all contacts with staff, health plan members, providers, peers and visitors. Assume accountability for assigned standards from the National Committee for Quality Assurance (NCQA), including oversight of delegated activities.
Work with UPMC Health Plan departments, such as Communication, Contracting, and Network Relations, Member Services, Claims Payment, Pharmacy Services, Utilization and Medical Management, Prevention and Wellness Services, Credentialing and other departments and delegates to ensure that NCQA standards are met and appropriate documentation is maintained. Work is conducted within the time parameters and in accordance with UPMC Health Plan Policies and Procedures, the Health Plan's Quality Improvement Description and Work Plan as well as the requirements and expectations of the Pennsylvania Department of Public Welfare, The Pennsylvania Department of Health and any other state or federal agencies and accreditation agencies.
Assist with the coordinated responses to Requests for Information or Proposals for the UPMC Health Plan Business Development staff related to the Quality Improvement program. Support the UPMC Health Plan Committee functions and activities as assigned. Ensure that meetings are organized, well documented and that they meet the Health Plan goals and objectives and the individual Committee's roles and responsibilities.
Participate in the Health Plan Effectiveness Data and Information Set (HEDIS�) program, including data collection and abstraction, performing root cause analysis, designing and/or implementing improvement plans, and monitoring and reporting results in accordance with the department's designated work plan. Demonstrate appropriate application of policies, procedures, and guidelines through continuous learning. Ensure that performance measurement is sufficient to produce meaningful and accurate results.
Consult, guide and instruct Health Plan employees on adherence to accreditation standards, HEDIS focused activities and other quality improvement initiatives. Assume accountability for assigned standards for Centers for Medicare and Medicaid Services (CMS) and /or Pennsylvania Department of Human Services (DHS) annual review standards, including oversight of delegated activities. Work with UPMC Health Plan departments and delegates to ensure that the CMS and DHS standards and reporting requirements are met.
Adhere to the UPMC Health Plan HIPAA Compliance Guidelines. Ensure that HIPAA standards are met in all aspects of the Department functions including delegated functions. Ensure that all releases of member personal health information, which are conducted outside of the realm of Treatment, Payment, or Operations are appropriately documented.
Bachelors' degree in a health care field or equivalent work experience required. 5 years of health care experience is required. Experience in network management and/or member services is preferred. For candidates without direct experience in these areas, strong data analysis and/or NCQA experience is highly preferred.
Data analysis experience preferred. Prior experience with NCQA accreditation is a bonus. Proficiency in Microsoft Word and Excel required; PowerPoint and Access proficiency preferred.
Excellent verbal, written and presentation skills are required. Professionalism, enthusiasm and initiative are expected. Ability to work independently and as productive team member is essential.
Knowledge of the National Committee on Quality Assurance (NCQA) Standards for the accreditation of managed care organizations Experience with data collection, analysis and management is a plus. Licensure, Certifications, and Clearances: Act 34 UPMC is an Equal Opportunity Employer/Disability/Veteran