Quality of Care Clinical Coordinator I (RN) - Hybrid

Quality Of Care Clinical Coordinator I

UPMC Health Plan is hiring a full-time Quality of Care Clinical Coordinator I to join the Quality Improvement team. This role will predominantly work remotely but will require in office presence once a month in downtown Pittsburgh's US Steel Tower.

This position coordinates and completes quality-of-care investigations, ensuring timely and compliant resolution across all intake channels. Manages multiple cases concurrently, conducts data analysis to identify quality improvement opportunities, and collaborates with Medical Directors and cross-functional teams through case review, documentation, administrative determinations, and case closure. This role supports regulatory compliance across all lines of business within the Quality Improvement department.

Responsibilities:

• Review, investigate, and complete case investigation related to quality-of-care concerns in required timeframes.
• Work closely with Special Investigations Unit (SIU), Network, Claims, Community Care Behavioral Health, Provider Services, Member Services, Medical Management, and Pharmacy Services to ensure review processes are understood and meet Health Plan strategy for appropriateness of quality-of-care referrals.
• Manage escalated member and provider issues as required.
• Review referrals for quality-of-care concerns, completes a comprehensive investigation summarizing clinical facts for the Medical Director review.
• Coordinate timely case review by a Health Plan Medical Director.
• Create correspondence for review prior to finalizing outreach to providers as needed to obtain and review additional clinical documentation, as well as provider and/or facility responses.
• Interpret Medical Director notes and summarize into correspondence for provider and/or facility.
• Report trends to leadership for improvement opportunities and provider education.
• Prepare documentation and summary for physician consultant peer review packets for designated specialized cases (i.e., pediatric neurosurgery) outline case and peer review needs
• Outreach to providers as appropriate to communicate decision.
• Collaborate with health plan business partners, as appropriate, for referral of investigation
• Build and foster collaborative relationships with internal and external stakeholders.
• Assist in the creation, enhancement, and implementation of process workflows for the QI, QOC Department.
• Assist with identifying continuing education needs and opportunities; maintain continuing education and appropriate CEUS required for RN licensure.
• Participate in quality improvement initiatives as assigned.

Registered nurse with a minimum of two years direct patient care experience required. PA RN license preferred. Two years of Health Insurance experience as a Registered Nurse in a Utilization Management/Medical Management/Care Management role strongly preferred. BSN is a bonus. HEDIS knowledge is a bonus. Experience with accountability for regulatory compliance for entities such as NCQA, CMS, Department of Public Welfare, Department of Health, and/or Pennsylvania Insurance Department preferred. Excellent verbal and written communications skills required. The ability to work in a fast-paced insurance environment and to manage multiple priorities/projects in a professional manner required. Working knowledge of ICD-9/ICD-10 and CPT classifications and coding of diagnoses and procedures preferred. Proficiency in computer skills required. Ability to collaborate effectively with physicians and other health care professionals. Strong organizational and critical thinking skills with ability to make decisions independently.

Licensure, Certifications, and Clearances:

• Registered Nurse (RN)
• Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran