Sr. Clinical Quality Program Administrator - Remote

UnitedHealth Group•Irvine, CA

3d•Remote

About The Position

This position serves as the subject-matter expert for Optum California’s grievance and Potential Quality Issue (PQI) programs. The role is responsible for proactively identifying performance improvement opportunities through 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. The role may function as an independent contributor or direct people manager, providing functional leadership, daily operational direction, and technical expertise to Grievance Operations and Quality Clinical Review managers, and oversight for a 24-member team. The position 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. The role is remote for those located in California and requires availability during Pacific Standard Time (PST) work hours.

Requirements

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

Nice To Haves

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

Responsibilities

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.
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.
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.