Responsible for assuring physician commitment and delivery of comprehensive high quality health care to UPMC Health Plan members. Oversees adherence to quality and utilization standards through committee delegations, and further establishes an effective working relationship between UPMC Health Plan’s Network and its physicians, hospitals and other providers.

Responsibilities:

Provide leadership direction for provider credentialing processes. Physicians must devote sufficient time to the CHC-MCO to provide timely medical decisions, including after-hours consultation, as needed Provide leadership and direction in meeting Quality Improvement and Care Management goals directed at improvements in member health status outcomes and established business strategies. Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan. Actively participates in the daily utilization management and quality improvement review processes, including concurrent, prospective and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns. Keep current with accepted standards and professional developments in the areas of quality improvement and utilization management. Communicate and educate network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes. Responsible for reporting the communication of reportable communicable diseases in accordance with statute. Interacts with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures. Work with the DOH State and District Office Epidemiologists in partnership with the designated county/municipal health department staff to appropriately report reportable conditions in accordance with 28 Pa. Code ??27.1 et seq. Daily interventions support implementation of the Health Plan’s Quality Improvement and Care Management Programs. Represent the Health Plan in external accreditation and certification activities. Act as first level physician reviewer for all cases referred by the Quality Improvement and Care Management Departments. Daily activities support adherence to quality and utilization standards, and establish an effective working relationship between UPMC Health Plan’s Network and its physicians, hospitals and other providers.