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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.

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