Quality Management Specialist (Behavioral Health)

UPMC Community Care Behavioral Health is hiring a full-time Quality Management Specialist. This role will work remotely Monday - Friday daylight hours EST. The ideal candidate has prior behavioral health experience.

The Quality Management Specialist is responsible for supporting the Quality Management Department through the coordination, monitoring, analysis, and reporting of quality improvement activities across UPMC Community Care Behavioral Health. This position focuses on ensuring compliance with Pennsylvania Department of Human Services regulations, NCQA, and other regulatory and accreditation requirements related to pre-service denials, member grievances, external grievances, fair hearings, quality oversight, auditing, reporting, and performance improvement initiatives. The Quality Management Specialist collaborates with internal departments, providers, oversight agencies, and leadership to ensure quality standards are met and opportunities for improvement are identified and addressed.

Must be legally authorized to work in the United States, without requiring, now or in the future, sponsorship for employment visa status. UPMC does not participate in STEM OPT.

Responsibilities:
 

• Denials, Grievances, and Regulatory Compliance
  •    Process and manage pre-service denials, member grievances, external grievances, and fair hearing activities across all county contracts.
  •    Facilitate and coordinate grievance meetings and related review processes.
  •    Log, track, monitor, and report denial, grievance, external grievance, and fair hearing activities.
  •    Participate in denial and grievance audits to ensure compliance with regulatory and accreditation standards.
  •    Provide support and consultation to departments involved in denial and grievance processes.
  •    Ensure all denial and grievance activities are conducted in accordance with Department of Human Services regulations, NCQA standards, contractual requirements, and organizational policies.
  •    Participate in Denial and Grievance team meetings and quality improvement activities.

• Quality Management, Reporting & Auditing

   

  •    Prepare, analyze, validate, and distribute quality management reports for leadership, committees, regulatory agencies, and oversight organizations.
  •    Collect, track, monitor, and maintain quality, denial, grievance, and operational data to support organizational performance and compliance requirements.
  •    Conduct targeted audits, quality reviews, and data validation activities to ensure compliance with regulatory, contractual, accreditation, and organizational standards.
  •    Identify trends, risks, and opportunities for improvement and collaborate with stakeholders to implement corrective actions and performance improvement initiatives.
  •    Support NCQA, Department of Human Services, and other accreditation or regulatory reviews, audits, and site visits.

• Communication and Collaboration
  •    Maintain effective working relationships with internal departments, providers, regulatory agencies, and community stakeholders.
  •    Participate in quality-related committees, including preparation of meeting materials, minutes, and follow-up documentation.
  •    Support outcomes, quality improvement, and other departmental initiatives as assigned by Denial & Grievance Manager.
  •    Perform duties in accordance with organizational values, competencies, and performance expectations.