Description

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

The Quality Improvement Coordinator (QIC) - Grievances is responsible for reviewing, researching, and resolving member grievances in accordance with regulatory, contractual, and organizational requirements. This role manages cases from intake through resolution, ensuring accuracy, timeliness, and high-quality documentation. The Coordinator collaborates with internal departments, health plans, and providers to gather information and support appropriate determinations. This position operates under the direction and oversight of the Quality Operations Manager and/or designated leadership, following established workflows and procedures.

Schedule: Monday to Friday, 7:30 AM-6 PM, PST, 40 hours/wk.

Location: Remote - Nationwide

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

Primary Responsibilities:

Review, research & analyze grievance information

• Receive and analyze grievance documentation to determine relevant details
• Review and reconsider determinations regarding reopened cases when appropriate
• Make outbound calls to health plans and/or providers for clarification
• Identify whether additional clinical or administrative reviews are needed. Obtain and review medical records for additional review levels
• Work collaboratively with claims, UM, provider groups, and other departments
• Support grievance audits and respond to regulatory or plan inquiries
• Manage all aspects of the grievance case process from intake to resolution

Utilize systems to track, document & communicate case progress

• Research case information across multiple internal systems
• Maintain complete and accurate documentation in grievance tracking systems
• Draft and send grievance acknowledgement, status, and outcome letters
• Edit documents for accuracy, clarity, and reading level
• Maintain confidentiality in accordance with HIPAA and internal guidelines
• Upload required documentation and ensure all records are complete prior to case closure
• Respond to escalated issues and represent the department professionally

Communication and Professional Conduct

• Communicate grievance status and outcomes professionally to internal and external stakeholders
• Respond to questions or follow-up requests related to assigned cases
• Escalate complex issues to leadership per established procedures

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:

• High School Diploma/GED
• 2+ years of experience working with appeals and grievances in healthcare
• 2+ years of experience with medical terminology
• Intermediate level of proficiency with MS Office

Preferred Qualifications:

• Minimum 1-3 years of experience in grievance, appeals, quality, or clinical operations
• Experience using referral management systems, electronic health records, or claims platforms
• Strong working knowledge of CMS, DMHC, NCQA, or other regulatory requirements related to grievances and appeals
• Ability to manage multiple cases, meet deadlines, and work independently in a fast-paced environment
• Excellent written and verbal communication skills, with the ability to draft clear and compliant member correspondence

*All Telecommuters 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 hourly pay for this role will range from $16.15 to $28.80 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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.

UnitedHealth Group 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.

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

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