Critical Incident Investigator I

UPMC Health Plan is hiring a full‑time Critical Incident Investigator to help support the UPMC Community HealthChoices Quality Improvement Department for its downtown Pittsburgh location at the US Steel Tower. This is a Monday through Friday daylight position. This is a remote position, but candidates must be located near Pittsburgh, PA. Community Health Choices 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:

• Monitor and manage multiple electronic intake queues to ensure timely and accurate critical incident reporting.
• Report, monitor, and update incident‑related information in electronic systems in compliance with Pennsylvania Office of Long‑Term Living requirements.
• Review reports and supporting documentation for completeness, accuracy, and required data elements related to long‑term services and supports.
• Collect, organize, and verify information from providers, service coordinators, and other sources to support accurate recordkeeping.
• Review medical records, service plans, assessments, and related documents to ensure data is properly recorded and maintained.
• Manage a high‑volume caseload of approximately 200–250 open incidents once fully onboarded, prioritizing tasks to meet accuracy, timeliness, and documentation standards.
• Maintain detailed, up‑to‑date electronic case records by documenting activities and outcomes in a timely manner.
• Prepare clear and concise incident summaries and data reports for management review, both written and verbal, as requested.
• Identify data discrepancies or documentation gaps and route them appropriately in accordance with organizational policies.
• Adhere to system‑wide standards, procedures, and productivity expectations.
• Perform additional administrative and data‑related duties as assigned.
• Bachelor’s degree in Human Services, Criminal Justice, or Social Work preferred; or Associate degree and 2 years of related work experience in investigations, criminal justice, service coordination, or long‑term services and supports at an administrative level.
• 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

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