Sr. Clinical Quality Program Administrator - Remote

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

Optum's Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.

Positions in this function require LPN or RN licensure with current unrestricted licensure in applicable state and may require certification based on role and grade level. Positions in this function serve as the subject-matter expert for Optum California's grievance and Potential Quality Issue (PQI) programs and are responsible for proactively identifying performance improvement opportunities through the use of data analytics, technology, workflow changes and clinical support. This role oversees end-to-end grievance and PQI workflows, ensures regulatory compliance (DMHC, CMS, NCQA, contracted health plans), and manages high-risk and sensitive escalations. This role may function as an independent contributor or direct people manager; providing functional leadership, daily operational direction, and technical expertise to the Grievance Operations and Quality Clinical Review managers, and oversight for a 24-member team spanning clinical nurses, coordinators and temp staff who support grievance management, audits, peer review, regulatory committees and quality reporting for four separate RKK-licensed entities and managed IPAs. The role is central to maintaining quality, accuracy, and timeliness across a rapidly integrating Optum department and organization. This position requires solid clinical and operational judgment, demonstrated experience managing complex quality investigations, and the ability to influence outcomes across multidisciplinary teams with no formal personnel authority.

If you are located in California, you will have the flexibility to work remotely* as you take on some tough challenges. California based preferred, must be available Pacific Standard Time (PST) work hours.

Primary Responsibilities:

Quality Improvement & Program Management

• Provide day-to-day operational direction for grievance and PQI activities across clinical and non-clinical staff, ensuring alignment with required turnaround times, internal workflows, and health plan expectations
• Serve as the subject-matter expert for multi-system operations during the transition from multiple legacy databases to a single market solution, advising on requirements, migration risks, and workflow impacts
• Lead end-to-end development, execution, and monitoring of quarterly QI Work Plans
• Coordinate, prepare, and facilitate quarterly Quality Improvement Committee (QIC) meetings for four regional entities (RKKs)
• Oversee Corrective Action Plans (CAPs) and responses to health plan inquiries related to grievance trends and performance
• Oversee accuracy and completeness of case documentation, ensuring required elements for regulatory review, internal audits, and health plan submissions are met
• Review Reportable Level Determination (RLD) events and collaborate with Risk Management on Potential Quality Issues (PQIs) for peer review

Grievance & PQI Management

• Serve as primary escalation contact for health plan grievances (5-30/week)
• Review, analyze, and respond to escalated cases in collaboration with clinical and operations leadership
• Provide clinical leadership for written responses related to missed turnaround times (TAT) and elevated grievance categories (e.g., 805 cases, access issues)
• Support interdepartmental coordination on escalation resolution (UM, CM, Network, Contracting)
• Represent Quality Improvement at Joint Operations Meetings (JOMs) with health plans
• Coordinate cross-functional responses (e.g., Risk, UM, CM, DO, Network, Legal, Compliance) and ensure timely, complete, and accurate submissions to plans
• Provide clinical guidance and decision support to nurse investigators on Level assignment, standards of care, and next-step actions
• Support Physician Leads and Medical Directors by preparing PQI summaries, case files, and documentation for Peer Review Committee deliberation

Regulatory & Audit Readiness

• Develop expertise in DMHC standards and crosswalks (QM, Access, Language, Grievances & Appeals) to support DMHC audits, re-audits, and CAP responses
• Oversee PQI case universe and documentation submission
• Serve as SME for grievance and PQI processes during audits and presentations
• Maintain committee documentation, confidentiality protocols, and reporting requirements aligned to the Quality Program Description
• Review monthly KPIs (TAT, case volumes, severity distributions, committee dispositions) and prepare summary reporting for leadership

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:

• Current, unrestricted RN /LVN license in California
• 2+ years of experience in Quality Improvement, managed care or clinical quality review
• Leadership, management or team-lead experience 
• Experience working with health plans, audits, and regulatory bodies (e.g., DMHC, CMS)
• Experience collaborating with clinical and operational leadership
• Proven solid analytical, problem-solving, and written communication skills
• Proven ability to manage multiple priorities and stakeholders in a fast-paced environment
• Proven ability to interpret and apply regulatory standards and ensure compliant workflows

Preferred Qualifications:

• Advanced degree (MPH, MHA, MSN, or similar field)
• Experience analyzing, synthesizing and reporting quality data for trend identification and decision-making 
• Experience in a delegated model medical group or large, multi-market organization
• Experience in grievance or appeals processes within a healthcare setting
• Experience with PQIs, peer review, and quality reporting tools
• Experience leading committees or cross-functional quality initiatives
• Direct experience with DMHC audits, TAGs, and compliance frameworks
• Knowledge of grievance and appeals processes in managed care
• Familiarity with evidence-based guidelines and quality standards
• Expert investigation and clinical review of quality-of-care concerns

*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 $112,700 to $193,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

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