Quality Improvement Manager – Remote

Optum CA is seeking a Quality Improvement Manager to join our team in El Segundo, CA. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

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 the Senior Director of Quality Improvement 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.  Let me know if you need additional information for the posting.

If you are RN or LVN licensed in state of CA you will have the flexibility to work remotely* 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 
• Facilitates Peer Review Committee operations as designated by PR Chair
• Manages PRC Minutes with attention to regulatory captures 
• In concert with Sr Director, identifies outside MD specialty reviewers as needed for cases
• Annually selects cases for IRR, reports to PRC and QI Committee

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 with Appeals and Grievances, Claims or Health Plan Customer Service
• 2+ years of experience managing work inventory to compliance metrics
• 2+ years of experience direct supervisor experience in managing or coordinating teams

Preferred Qualifications:

• 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

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

The salary range for this role is $89,800 to $176,700 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.