Job Information
UPMC Quality Management Clinician (Hybrid) in Tobyhanna, Pennsylvania
UPMC Community Care Behavioral Health is seeking a full-time Quality Management Clinician to support the Quality Department in Tobyhanna, PA!
The Quality Management Clinician will work daylight hours, Monday through Friday, in a hybrid work structure! This role will support the Carbon-Monroe-Pike (CMP) contract, which does include some limited local travel out in the community to provider sites. The Quality Management Clinician will primarily be able to work from home, with limited office time required for quarterly meetings and for any as-needed events.
Community Care Behavioral Health (CCBH) is committed to giving our neighbors the quality of life that they deserve. A proud part of the UPMC Insurance Services Division, CCBH provides members with the behavioral health treatment that they need for better health and a higher quality of life, including treatment for mental health conditions, drug or alcohol addiction, and developmental disabilities.
Under the direction of the Manager of Quality Management, the Quality Management Clinician is responsible for performing functions related to quality management and improvement in compliance with NCQA, HEDIS, URAC, and the Commonwealth of Pennsylvania Department of Health quality assurance regulations. The role will support activities including, but not limited to, record reviews, audits, member complaint investigations, and Significant Member Incidents (SMIs).
Responsibilities:
Responsible for participating in projects as designated by other management staff, such as the Chief Medical Officer and VP of Medical Affairs.
Responsible for performing targeted, clinical audits and focus studies.
Responsible for logging in, tracking, monitoring, and reporting individual and aggregate complaints and grievances to the Senior Director of Quality Management and other leadership staff members, as appropriate.
Prepares formal reports and tracks timing of various levels of complaint and grievance for further action.
Responsible for assisting with preparation for NCQA, URAC, and other site visits.
Responsible for participating in updating the QM Plan.
Responsible for monitoring quality tracking reports and providing individual feedback to appropriate staff/committees, as well as aggregating the data on a monthly basis.
Responsible for identifying trends related to product and participating providers.
Responsible for preparing monthly and quarterly quality improvement reports for the Board.
Responsible for specified data collection related to all functional departments of Community Care.
Responsible for assisting with training responsibilities for providers, members, and staff on various issues as assigned by the Senior Director of Quality Management.
Responsible for professional and staff development plans.
Licensed Registered Nurse OR Master's Degree.
BSN preferred with RN license.
PA Licensure preferred with Master's Degree.
3 years of clinical experience.
Demonstrated clinical knowledge of behavioral health-related issues.
Experience in Quality Management procedures/processes preferred.
Knowledge of URAC, NCQA, and HEDIS standards preferred.
Experience in managed care preferred.
Excellent organizational skills.
Experience in report writing, Microsoft Access, Microsoft Excel, and collection and organization of large quantities of data.
Ability to maintain effective professional liaison with all levels of staff, including professional and institutional providers of care.
Independent problem solving related to job responsibilities based on knowledge of quality standards, clinically pertinent issues related to product and population served, and the operating practices of this organization.
Ability to identify trends or problem areas.
Ability to propose and, with supervision, implement solutions to identified trends or problem areas with recommendations for improvement.
Excellent clinical, written, and verbal communication skills.
Responsiveness to deadlines and has work completed on or before deadline 95% of the time.
Licensure, Certifications, and Clearances:
Pennsylvania licensure: LSW, LCSW, LPC, licensed MFT, licensed RN (with BSN) and/or a licensed PhD (psychologist) preferred.
Act 31 Child Abuse Reporting
Act 33
Act 34
Act 73 FBI Clearance
UPMC is an Equal Opportunity Employer/Disability/Veteran