[Hiring] Critical Incident Investigator @UPMC

Role Description

UPMC Health Plan is hiring a full-time Critical Incident Investigator to join the UPMC Community HealthChoices Quality Improvement department. This role will work Monday through Friday daylight hours EST. You will manage a high volume of critical incidents in a fast-paced environment, ensuring timely, accurate, and compliant resolution.

• Manage a high volume of critical incidents.
• Ensure timely, accurate, and compliant resolution.
• Strong computer proficiency to navigate multiple systems simultaneously.
• Excellent organization to track, investigate, and meet strict deadlines.

The ideal candidate has experience working in a remote, productivity-driven environment and is comfortable managing a high-volume caseload.

• Highly computer proficient with strong Excel skills.
• Background in healthcare, quality, safety, or other high-responsibility, fast-paced home-based roles preferred.

Community HealthChoices 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).

The successful candidate will report, track, and manage critical incidents for Community HealthChoices (CHC) participants.

• Ensure critical incidents are responded to thoroughly, effectively, and timely.
• Work closely with Complaints & Grievances, service coordinators, quality improvement coordinators, and other staff in the health plan.
• Investigate incidents, trends, Quality of Care concerns.
• Ensure all parties required are contacted within specified timelines.
• Collect and analyze Incident Reporting data for quality measures, timeliness of response, and effective resolution.

Qualifications

• Bachelor's degree in Human Services, Criminal Justice, or Social Work preferred; or Associate's degree and 2 years of related work experience in investigations, criminal justice, service coordination, or long-term services and supports at an administrative level.
• Prior experience in healthcare, quality, auditing, emergency response, or public safety strongly preferred.
• Computer proficiency strongly preferred.
• Prior experience with medical records is a bonus.
• 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.

Requirements

• Self-motivated, self-directed/disciplined.
• Manage time effectively and work efficiently to meet strict deadlines for filing incidents timely and thoroughly.
• Critical thinking skills to raise vital questions and problems with the participant's situation or services.
• Formulate recommendations for risk mitigation.
• Gather and assess relevant information from various health systems.
• Evaluate actions taken to close cases when risks have been mitigated or reduced.
• Adjust the investigation process as state standards and expectations have increased conclusions and solutions.
• Actively engage in discussions with peers, service coordinators, and supervisors for new interventions, resources, training needs, and quality improvement strategies.
• Communicate effectively with various parties to propose interventions, resources, or solutions to complex situations.
• Monitor and screen various intake queues for critical incidents to report to the Pennsylvania Office of Long-Term Living.
• Report and investigate critical incidents reported to the health plan regarding participants in long-term services and supports.
• Interview providers and service coordinators to collect and evaluate relevant information.
• Review medical records, service plans, assessments, and other collateral information to recommend follow-up actions needed to mitigate risk.
• Document findings in electronic systems and actively record all activities on open cases in a timely manner.
• Provide incident summary responses both orally and in writing to various managers by request.
• Identify and address provider non-compliance in accordance with health plans policy.
• Perform in accordance with system-wide competencies/behaviors.
• Perform other duties as assigned.

Licensure, Certifications, and Clearances

• Act 34 with renewal.

Company Description

UPMC is an Equal Opportunity Employer/Disability/Veteran.