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. This role requires strong computer proficiency to navigate multiple systems simultaneously, along with 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. They must be highly computer proficient, with the ability to navigate multiple systems and screens simultaneously and possess strong Excel skills. A background in healthcare, quality, safety, or other high-responsibility, fast-paced home-based roles—such as call centers, medical record auditing, 911 dispatch, quality assurance)—is 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). 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. 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 timely 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:
- A CII needs to be self-motivated, self-directed/disciplined, manage their time effectively, and work efficiently to meet strict deadlines for filing incidents timely and thoroughly.
- The CII must have critical thinking skills to: Raise vital questions and problems with the participants situation or services. Formulate recommendations for risk mitigation. Gather and assess relevant information from various health systems, and gain understanding of clinical terms and recommendations. Evaluate actions taken to close cases out when risks have been mitigated or reduced and preventative actions and/or corrective actions are implemented. 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, including allegations of abuse, neglect or exploitation of person or property.
- 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 participants 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
- 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.
- Performs in accordance with system-wide competencies/behaviors Performs other duties as assigned
- Bachelors degree in Human Services, Criminal Justice, or Social Work preferred; or Associates 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.
Licensure, Certifications, and Clearances:
- Act 34
UPMC is an Equal Opportunity Employer/Disability/Veteran