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Director, Delegation Compliance - Remote


Medical Director


El Segundo, California, United States

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. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life's best work.(sm)

Positions in this function is responsible for developing, integrating, implementing, and monitoring compliance with the Utilization Management and Care Management Plans including policies and procedures across health plans, NCQA and other regulatory agencies. Works with the Senior Director Delegation Compliance Clinical Services on continuous process optimization to provide support and leadership in the integration of Optum’s delegation compliance teams. Serves as a liaison between Optum Clinical Services and health plans, state and federal governing agencies. Clinical Services, Quality Improvement, Risk Management, Contracting and national compliance partners.

The Director maintains organizational structure and oversight of procedures, employment, training, and supervision of all medical management compliance staff. The Director coordinates duties with appropriate personnel to meet operational program needs and ensures compliance with state and federal health plan requirements, Medicare guidelines, NCQA and URAC standards. The Director implements policy and procedures to maintain corporate and service initiatives. The Director integrates current clinical practice guidelines for care management services.

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

Primary Responsibilities:

  • Supports the integration of Optum CA Delegation Compliance for Clinical Services in collaboration with the Senior Director, Delegation Compliance, Clinical services, Optum CA market QI and national compliance partners
  • Supports scaling the compliance program across CA to ensure adherence to all state, federal and other applicable accreditation standards. Includes, but not limited to internal and external audits, compliance reports, appeals, letter management
  • Participates in the development, implementation and oversight of people, processes and technology required to comply with Optum California’s delegation oversight of clinical services
  • Serves as an active partner across clinical services to ensure Clinical Services strategy and initiatives are in adherence with applicable state and federal regulatory guidelines
  • Supports implementation of a market strategy for the submission of health plan compliance reports and ensures the submission of CM reports in a timely manner
  • Implements a CA market compliance letter management process in collaboration with Optum national
  • Actively collaborates with internal stakeholders and external partners, payers, and regulatory agencies to transform the health care experience for Optum customers and members
  • Supports efforts to achieve financial performance consistent with division and market goals
  • Acts as a central resource regarding regulatory requirements from participating regulatory agencies as well as health plan clinical review criteria and managed care benefits
  • Ensures consistency and compliance of Clinical Services delegated functions in accordance with state, federal, health plan delegation, and NCQA requirements. Makes recommendations for any revisions to the UM and/or CM plan to accommodate these requirements
  • In collaboration with the Senior Director Delegation Compliance, Clinical Services, cultivates the culture, systems, and processes that support consistent audit-readiness. Ensures internal audits are conducted, reviews results, formulates and implements appropriate action plans to correct any areas of noncompliance. Develop and oversee implementation of Corrective Action Plans as needed
  • Encourages staff to develop skills and knowledge for personal growth and promotion of position. Fosters leadership skills for supervisor/manager positions to ensure qualified staff perform management of processes. Promotes appropriateness in the utilization of staff by being flexible and assisting others when a staffing problem occurs. Identifies and helps develop future leaders
  • Actively participate in the development of policies, programs, and initiatives that improve Employee Engagement, Diversity & Inclusion and Drive our Health Equity Goals
  • Performs additional duties as assigned

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:

  • Bachelor’s degree and/or equivalent experience
  • 5+ years of experience in managed care and/or care management
  • Team management experience
  • Knowledge of federal and state laws and NCQA regulations relating to managed care, utilization management, model of care and complex care case management

Preferred Qualification:

  • Master’s degree

Professional Competencies:

  • Solid clinical leadership skills to ensure trust and respect of clinical staff
  • Solid operational mindset and ability to use data to draw insights
  • Solid ability to communicate in written and verbal presentations
  • Solid relationship development and team management skills
  • Results oriented, capable of clearly translating strategic objectives into implementation plans that drive outcomes
  • Success in driving organizational change and performance improvement
  • Solid collaboration skills to ensure effective alignment among diverse teams
  • Ability to excel in a matrixed environment

Work Environment:
Most work responsibilities are performed remotely or in an office setting, carrying out detailed work sitting at a desk/table and working on the computer. Travel may be required

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

California, Colorado, Connecticut, Nevada, New York City, or Washington Residents Only Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New York City, or Washington residents is $101,200 to $184,000. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

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.

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.