Sr. Clinical Quality Program Administrator - RemoteStryker Corporation • Irvine, California, United States
Sr. Clinical Quality Program Administrator - Remote
Stryker Corporation
- Irvine, California, United States
- Irvine, California, United States
Über
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:
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
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
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. 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.
All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.
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.
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Sprachkenntnisse
- English
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