Job Description

Job Title: Clinical Improvement Specialist
Job ID: 736061
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Network Management
Location: 600 Grant St, Pittsburgh PA 15219

Description

Purpose:
UPMC Health Plan is seeking a Clinical Improvement Specialist for their Network Management Department!


This job is directly responsible for implementing the value creation strategy for each of the primary care provider groups (Partners) enrolled in the UPMC Health Plan's Value-based Reimbursement program. In this role, the Clinical Improvement Specialist works directly with primary care providers and their office staff to support them in clinical improvement activities that will allow for Partners to achieve clinical, quality, and financial performance goals and/or ROI targets identified for the Partner's member population. 


 This job is a highly skilled subject matter expert in quality (Medicare STARS, Medicaid HEDIS, etc.) and works closely with the internal UPMC Health Plan staff and PCP practices for the regular review and analysis of their performance in quality. This job also has subject matter expertise in continuous quality improvement and can work with primary care providers and their office staff to identify and design new processes and practice workflows that will enable the transformation of care delivery to better support Partners in achieving their goals. 


 The individual in this role must be able to work collaboratively in a matrixed environment, have strong interpersonal skills, be organized and self-directed, and enthusiastically represent the Organization and its mission and goals.


This is primarily a field-based role with 80% of the time spent traveling and visiting physician practices with the other 20% dedicated to time at the UPMC Health Plan offices.

Responsibilities:

  • • Provides assistance and support to assigned physician practices enabling them to resolve daily operational issues including claims and network-related inquiries
  • Collaboratively works with the Partner to implement the performance improvement strategies in conjunction with the UPMC Health Plan internal team. Manages all the information necessary to track progress on the Partner-specific value-based reimbursement strategic plan.
  • Provides assistance and support to assigned physician practices enabling them to resolve daily operational issues including claims and network-related inquiries
  • Provides assistance to the PCPs and their office staff in the use of user interfaces, population health management and/or quality tools supported by UPMC Health Plan.
  • Serves as the on-site quality improvement and best practices champion for primary care practices bringing together various UPMC Health Plan field-based efforts into a coordinated on-the-ground approach that supports Partners in achieving goals in value-based reimbursement.
  • Serves as the on-the-ground clinical subject matter for quality (Medicare STARS, HEDIS) and supports practices with this knowledge and expertise. Works collaboratively with the internal UPMC Health Plan quality team to translate quality insights into best for the PCPs.
  • Works with the Partner to assess current state and facilitates workflow redesign to help the Partner implement best practices, better incorporate data-driven insights, and/or use the right tools to help the Partner achieve performance goals. Uses continuous quality improvement methodologies to facilitate improvement and change.
  • Works with the UPMC Health Plan internal team to identify and develop specific performance improvement strategies that will support a given Partner achieve performance goals.

Qualifications

  • Clinically-trained and/or demonstrated experience working in outpatient clinical settings
  • Three to five (3-5) years of experience in managed care and/or physician practice management required.
  • Experience with Medicare STARS, Medicaid HEDIS, and population health management
  • Analytical and organization skills required.
  • Excellent written and verbal communication skills is required.
  • Preferred: Masters degree in a business or health care field
  • Experience in Lean, Six Sigma, TQI, TQC, or other quality management certification
  • Experience in network performance management and/or continuous quality improvement

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

Salary Range: $30.89 to $52.76

Union Position: No

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