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

UnitedHealth Group•El Segundo, CA

4d•$91,700 - $163,700•Remote

About The Position

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.

Requirements

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

Nice To Haves

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

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