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Quality Director, Utilization Management - Telecommute

UnitedHealth Group

Boston, MA
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Job Details

746340 Quality Director Utilization Management Telecommute

Quality Director, Utilization Management - Telecommute (746340)

Position Description

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 and help people live healthier lives while doing your life's best work.(sm)


The Quality Director, Utilization Management is a lead position and is accountable for the quality oversight of employees that perform utilization management. 


You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.



Primary Responsibilities:

  • Quality oversight of leadership, structure, policies and procedures, monitoring and oversight processes to ensure overall outcomes and optimal UM program performance

  • Performs quality oversight of the daily UM operations

  • Conduct audits of prior authorizations and Secondary Reviews to confirm the member’s needs and that LTSS services are allocated appropriately in accordance to regulations and medical necessity guidelines

  • Conduct  peer to peer consultations as appropriate

  • Coordinates monthly and annual quality reporting, inclusive of all prior authorization requests upon request

  • Training of internal utilization management team

  • Assist with LTSS provider communications and process education

  • Process inter - rater reliability (IRR) study results providing feedback at the individual level

  • Implement quality and process improvement plans

  • Examine utilization, cost, and quality measures across LTSS services, differences across providers and regions, and service utilization consistency with member clinical and functional assessment data

  • Provide monthly PA and UM Activity reports with recommendations for improvements and associated cost impact assessment

  • Validate and review appeals audits with reporting of results

  • Analyze the rate and reasons of prior authorization modifications, denials, appeals, and overturns by provider type

  • Actively participate in the Quality Improvement Committee and LTSS Provider Quality Forum to identify improvement opportunities promptly and address them

  • Perform audit appeals specific to quality while ensuring compliance measures are being met

  • Support continuous improvement of annual employee engagement scores

Required Qualifications:

  • A current, unrestricted Registered Nurses license to practice in the state of residence
  • Holds a Bachelor’s Degree of Nursing
  • Minimum of 5 years clinical nursing experience inclusive of Utilization Management  / Quality Improvement experience and / or experience working with individuals receiving LTSS services
  • 5 years in a Directorship role in Utilization Management, preferably within a Managed Care environment
  • Ability to accurately interpret benefits and effectively clinical guidelines
  •  Solid computer skills
  • Ability to build and maintain relationships is essential
  • Effective communication skills, flexibility and displays positive attitude

 Preferred Qualifications:

  • Medicaid and / or LTSS Population Health Management experience
  • Appeals experience
  • Process improvement implementation and / or training experience

UnitedHealth Group is working to create the health care system of tomorrow.

Already Fortune 6, we are totally focused on innovation and change. We work a little harder. We aim a little higher. We expect more from ourselves and each other. And at the end of the day, we're doing a lot of good.

Through our family of businesses and a lot of inspired individuals, we're building a high-performance health care system that works better for more people in more ways than ever. Now we're looking to reinforce our team with people who are decisive, brilliant - and built for speed.

Come to UnitedHealth Group, and share your ideas and your passion for doing more. We have roles that will fit your skills and knowledge. We have diverse opportunities that will fit your dreams.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.


Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

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


Job Keywords: LTSS, Utilization Management, Prior Authorization, Managed Care, Boston, Massachusetts, Registered Nurse, Medicaid, Nursing, Clinical, Director, Leadership

Job Details

  • Contest Number746340
  • Job TitleQuality Director, Utilization Management - Telecommute
  • Job FamilyNursing
  • Business SegmentOptum Corporate

Job Location Information

  • Boston, MA
    United States
    North America
  • Other LocationsChicago, IL
    Atlanta, GA
    Dallas, TX
    Nashville, TN
    Minneapolis, MN

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelDirector
  • ShiftDay Job
  • TravelNo
  • Telecommuter PositionYes
  • Overtime StatusExempt

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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