Job Description

Job Title: Coordinator, Quality Improvement [RN]
Job ID: 719392
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Quality Improvement
Location: 600 Grant St, Pittsburgh PA 15219

Description

UPMC Health Plan is hiring a full-time Coordinator, Quality Improvement to help support the Quality Improvement Department for its downtown Pittsburgh location at the US Steel Tower. This is a Monday through Friday daylight position.

 

The successful candidate will coordinate QI activity and supports various functions within the scope of the Health Plan Quality Improvement Program, working both independently and as a team member. The functions include but are not limited to physician education and improvement initiatives, committee support, regulatory and accreditation standard adherence, delegation oversight, performance monitoring and assessment, clinical practice guideline management, data collection, abstraction and analysis and the continual advancement of the quality improvement process as a means to achieve the Health Plan's goals of excellence.

Responsibilities:

  • 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.
  • 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.
  • 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.
  • 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.
  • Coordinate and conduct network physician education, initiatives related to HEDIS including HEDIS measure education, review of physician profiles and planning and implementation of improvement initiatives.
  • Demonstrate appropriate application of policies, procedures, and guidelines through continuous learning. Ensure that performance measurement is sufficient to produce meaningful and accurate results. Council, guide and instruct Health Plan employees on adherence to accreditation standards, HEDIS focused activities and other quality improvement initiatives.
  • 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.
  • 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.
  • Support and champion UPMC Health Plan safety initiatives as assigned.
  • Support the Health Plan's Complaint and Grievance process as needed including: Attending complaint and grievance hearings, serving as a voting member as needed. Conducting quality of care reviews, coordination of follow up, reporting of the activities and monitoring corrective action plans.
  • 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.
  • 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.

Qualifications

  • Bachelors degree in a health care field or equivalent work experience required. BSN or RN is preferred.
  • Health related Masters is preferred.
  • 5 years of health care experience is required.
  • 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 HEDIS specifications; the managed care environment and the basic tenets of continuous quality improvement are strongly preferred
  • Experience with data collection, analysis and management is a plus.

    Licensure, Certifications, and Clearances:
    UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $26.64 to $44.88

Union Position: No

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