Quality Management Clinician Jobs

UPMC Community Care Behavioral Health is seeking a full-time Quality Management Clinician to support the Quality Department and their Dubois-area territory!

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.

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. Along with record reviews and audits, this role will work heavily with reports, member incident report reviews, and complaint reviews.

The Quality Management Clinician will work daylight hours, Monday through Friday, in a hybrid work structure! While some occasional travel to provider sites and other organizations is expected, this position will primarily work from home. Travel requirements ebb and flow due to business needs, as do occasional in-person departmental meetings.

Responsibilities:

• Responsible for preparing monthly and quarterly quality improvement reports for the Board.
• Prepares formal reports and tracks timing of various levels of complaint and grievance for further action.
• 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 assisting with preparation for NCQA, URAC, and other site visits.
• Responsible for identifying trends related to product and participating providers.
• Responsible for logging in, tracking, monitoring, and reporting individual and aggregate complaints to the Senior Director of Quality Management and other leadership staff members, as appropriate.
• Responsible for specified data collection related to all functional departments of Community Care.
• Responsible for performing targeted, clinical audits and focus studies.
• 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 participating in updating the QM Plan.
• Responsible for professional and staff development plan.
• Responsible for participating in projects as designated by other management staff, such as the Chief Medical Officer and VP of Medical Affairs.

• Ability to propose and, with supervision, implement solutions to identified trends or problem areas with recommendations for improvement.
• Demonstrates clinical knowledge of behavioral health-related issues.
• Excellent organizational skills.
• Ability to maintain effective professional liaison with all levels of staff, including professional and institutional providers of care.
• Responsiveness to deadlines and has work completed on or before deadline 95% of the time.
• 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.
• Experience in report writing, Microsoft Access, Microsoft Excel, and the collection and organization of large quantities of data.
• 3 years of clinical experience required.
• Registered Nurse OR Master's Degree required.
  • BSN and/or PA Licensure preferred.
• Experience in Quality Management procedures/processes preferred.
• BSN and/or PA Licensure preferred.
• Experience in managed care preferred.
• Ability to identify trends or problem areas.
• Knowledge of URAC, NCQA, and HEDIS standards preferred.
• Excellent clinical, written, and oral communication skills.

Licensure, Certifications, and Clearances:
Pennsylvania licensure: LSW, LCSW, LPC, licensed MFT, licensed RN (with BSN), and/or a licensed PhD (psychologist) preferred.

• Act 33 with renewal
• Act 34 with renewal
• Act 73 FBI Clearance with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran