UnitedHealth Group

Manager, Quality Management - Clinical Review - Remote (PST Work Hours)

UnitedHealth Group$91K — $163K *
US-AnywhereRemote in El Segundo, CA
Healthcare
Less than 5 years of experience
Job Overview by Ladders

Qualifications

  • Graduation from an accredited nursing school
  • Active RN or LVN license from California
  • 2+ years in grievance, quality, or clinical operations
  • 2+ years managing compliance metrics
  • 2+ years of supervisory experience
  • Ability to work PST hours

Responsibilities

  • Monitor grievance database for case reporting and productivity
  • Run trend reports by provider and issue severity
  • Facilitate team meetings for productivity and process support
  • Identify Quality of Care PQIs for investigation
  • Implement quality assurance processes for documentation
  • Manage PRC minutes with regulatory attention
  • Identify outside MD specialty reviewers for cases
  • Cover staff absences and adjust assignments
  • Serve as clinical contact for complex escalations
  • Lead peer review process for nursing and interdisciplinary cases

Benefits

  • Comprehensive benefits package
  • Incentive and recognition programs
  • Equity stock purchase
  • 401k contribution
  • Far-reaching choice of benefits and incentives
Full Job Description
This position is responsible for the day-to-day management of the clinical staff (QI Nurses) within the Grievance/ Peer Review Lane of the Optum CA Quality Improvement Department. The role reports directly to Quality Improvement Leadership and collaborates with QI Ops Manager and clinical staff (QI Nurses) to manage health plan grievance and potential quality issue case productivity, turn-around-times and quality.

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

  • Monitors grievance database open and closed case reporting and productivity to ensure that all potential quality issues are investigated in a timely manner
  • Runs and monitors trend reports by provider, by issue and by level of severity of confirmed problems
  • Facilitates team meetings and open case review touchpoints as needed to monitor productivity and process, support team and provide updates
  • Identifies Quality of Care PQIs for QI investigation and coding/leveling through the PRC process.
  • Implements quality assurance processes (ex. chart audits) to monitor quality of documentation and case review
  • Manages PRC Minutes with attention to regulatory captures
  • In concert with Sr. Clinical Quality Program Administrator identifies outside MD specialty reviewers as needed for cases
  • Provide coverage plans for staff absences and adjust the clinical assignments to maintain compliance with turn-around-times (TATs)
  • Serve as the first point of clinical contact for complex clinical cases or complex escalations
  • Lead and coordinate the peer review process for nursing and interdisciplinary cases: case selection, reviewer assignment, agendas, materials, and scheduling


You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Graduation from an accredited school of nursing
  • Active Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license through the State of California
  • 2+ years of experience in grievance, quality, or clinical operations role.
  • 2+ years of experience managing work inventory to compliance metrics
  • 2+ years of direct supervisor experience in managing or coordinating teams
  • Ability to work PST work hours


Preferred Qualifications:

  • Demonstrated experience in developing and implementing workflows and processes, especially in transitioning to new systems, such as grievance databases
  • Experience with Case Management, Inpatient or Ambulatory care settings
  • Knowledge of health plan turnaround times and commitment to meeting or exceeding performance metrics
  • Proficient in learning, adapting to, and implementing new systems and technologies
  • Proficiency in Excel
  • Proven comfortable with using databases, tracking tools, and other relevant software for quality improvement and grievance management
  • Proven skilled in creating and optimizing workflows to enhance team productivity and effectiveness
  • Reside in CA


*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $91,700 to $163,700 annually based on full-time employment. We comply with all minimum wage laws as applicable.

About UnitedHealth Group

UnitedHealth Group is a medical facility. They offer health technology, health finance, and pharmacy services. They are utilizing clinical data and intelligence to assist in the redesign, automation, and deployment of technology to streamline administrative operations and clinical decision-making. Payment systems for both consumers and providers are critical components of a health-care system.

UnitedHealth Group Careers

Joining UnitedHealth Group means becoming part of a diverse team dedicated to making a difference. As a leader in health services and innovation, our company offers a variety of job opportunities that allow professionals to leverage their skills, drive innovation, and improve lives. Work You’ll Do At UnitedHealth Group, you’ll contribute to a mission-focused environment where your expertise will influence the health and well-being of people worldwide. Our employment opportunities span across a wide range of disciplines, from healthcare specialists to data analysts, ensuring that your career journey is both dynamic and rewarding. Transform Healthcare with Your Expertise UnitedHealth Group stands at the forefront of health innovation. Our team collaborates to deliver solutions that lead to better patient outcomes. Working with us, you’ll find yourself at the intersection of technology, healthcare, and leadership, providing key insights that drive industry transformation. Join Our Global Team As part of our team, you’ll engage with over 300,000 professionals globally, dedicated to building a diverse and inclusive workplace. UnitedHealth Group is not just a company; it’s a community where you can grow your career through continuous learning and leadership opportunities. Our commitment to diversity training ensures that every team member can thrive. UnitedHealth Group Career Development We are committed to your professional growth. Explore career paths filled with promising job opportunities and internships that will harness your potential and expand your capabilities. Whether you’re a seasoned professional or a recent graduate, you’ll find that our career development programs support your ambition at every level. Innovative Work Environment At UnitedHealth Group, innovation is at the core of our operations. We encourage our team to bring forward-thinking ideas that challenge the status quo and lead to breakthrough improvements in patient care. Be Part of a Great Team Our culture fosters a collaborative and supportive environment where every member’s contribution is valued. Enjoy the benefits of being part of a global team that’s committed to making a difference in people’s lives. Future-Proof Your Career With UnitedHealth Group, your career is future-proof. Dive into a range of positions that offer both challenges and rewards. Our robust support system includes unmatched training, development programs, and certification support to propel your career forward. Stay Connected Join Our Team Discover the right position that matches your skills and interests. We are always hiring and look for passionate, curious, and solution-driven team players. Search UnitedHealth Group jobs today and take the first step towards a fulfilling career. Keep Up to Date Stay informed with career tips, insider perspectives, and industry-leading insights you can use today—all from the people who work here. Read Careers Blog Job Alert Emails Customize your subscription to receive job alerts, the latest news, and insider tips tailored to your preferences. Explore the exciting and rewarding opportunities that await at UnitedHealth Group.
Learn more about UnitedHealth Group
Size
350,000 employees
Market Cap
$493.1 billion
Industry
Net Income
$15.4 billion
Founded
1974
5 Year Trend
+9.2%
Revenue
$257.1 billion
NASDAQ

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