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Coordinates 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 HEDIS medical record review and data abstraction, audit support, as well as contributing to physician education and the continual advancement of the quality improvement process as a means to achieve the Health Plan's goals of excellence. Health plan and HEDIS measure experience is highly preferred.

Responsibilities:

- Support and champion UPMC Health Plan quality and safety initiatives as assigned.

- 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.

- 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 Human Service, The Pennsylvania Department of Health and any other state or federal agencies and accreditation agencies.

- 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.

- Demonstrate appropriate application of policies, procedures, and guidelines through continuous learning. Ensure that performance measurement is sufficient to produce meaningful and accurate results. Council and instruct Health Plan employees on adherence to accreditation standards, HEDIS focused activities and other quality improvement initiatives.

- 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.

- 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.

- 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.

- Bachelor's 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/Disability/Veteran