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DescriptionCommunity HealthChoices (CHC) is Pennsylvania's managed care long-term services and supports (LTSS) program serving seniors and individuals with physical disabilities in the Commonwealth who are covered by Medicare and Medicaid.This position is remote but may require occasional travel into the office.UPMC Health Plan is hiring a full-time Critical Incident Investigator to help support the UPMC Community HealthChoices Quality Improvement Department for its downtown Pittsburgh location at the US Steel Tower. Community Health Choices will impact more than 400,000 people statewide who are dually eligible for Medicare and Medicaid or receive Medicaid-funded long-term services and supports (LTSS). Through Community HealthChoices (CHC), we coordinate physical health care and LTSS to enhance the quality of life and independence for frail seniors and adults with disabilities in-home and community-based environments as well as in institutional settings. This is a Monday through Friday daylight position. The successful candidate will report, track, and manage critical incidents for Community HealthChoices (CHC) participants. This position will ensure critical incidents are responded to thoroughly, effectively, and time and work closely with Complaints & Grievances, service coordinators, quality improvement coordinators, and other staff in the health plan to investigate incidents, trends, Quality of Care concerns, and ensure all parties required are contacted within specified timelines. Incident Reporting data will be collected and analyzed for quality measures, timeliness of response, and effective resolution.Responsibilities:Document findings in electronic systems and actively record all activities on open cases in a timely manner.
Monitor various intake queues for critical incidents to report to the Pennsylvania Office of Long-Term Living.
Interview providers and service coordinators or other parties to collect and evaluate relevant information and make decisions related to the investigation, provider actions, and contacts needed to other units or agencies to assure the participant?s safety.
Review medical records, service plans, assessments and other collateral information to recommend follow up actions needed to mitigate risk and prevent further incidents from occurring
Provide incident summary responses both orally and in writing to various managers by request.
Report and investigate critical incidents reported to the health plan regarding participants in long term services and supports, including allegations of abuse, neglect or exploitation of person or property.
Identify and address provider non-compliance in accordance with health plan's policy.
QualificationsBachelor's degree in Human Services, Criminal Justice, or Social Work (if degree not in one of these three, 1 year of health plan/Medicaid line of business experience or related experience with Protective Services, Fraud Investigations, or LTSS will suffice).
Or Associate's degree and 2 years of related work experience (investigations, criminal justice, service coordination, or long-term services and supports at an administrative level).
Knowledge of commercial, Medicaid, Medicare products, managed care principles, and home and community-based services preferred.
Competent in MS Word, Outlook, Excel, web-based healthcare applications.
Strong organizational, interpersonal, and verbal and written communication skills.
Ability to successfully meet deadlines and manage multiple priorities in a fast-paced environment.
Strong critical thinking, judgment, and problem-solving skills.
Licensure, Certifications, and Clearances:UPMC is an Equal Opportunity Employer/Disability/VeteranREQNUMBER: 575406357
Vacancy expired!