Quality Claims Manager

Requisition Number: 2396765
This position is National Remote. You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.
Join us to start Caring. Connecting. Growing together.
Optum, a part of the UnitedHealth Group family of businesses, continues to evolve and make a bigger impact through its extensive expertise in combining technology, data and people to create novel health care solutions and services across the globe. OptumServe is following suit by creating and delivering care that meets the health needs of active-duty service members, veterans and their families. We're partnering with federal and state government agencies to meet the readiness and health needs of active-duty military members and veterans by providing preventive health screenings and assessments to ensure that troops are ready to answer the call of duty. For those who want to intensify their impact in a career that brings together challenge, learning and growth, OptumServe is the right place to do your life's best work.
The Manager, Claims Quality leads the day-to-day work of the Claims Quality team and is accountable for quality planning, quality assurance, quality control, and continuous improvement across Medical, Dental, and Pharmacy Claims. The role provides people leadership, directs claims-quality audits and calibrations, monitors quality and operational performance, strengthens governance and controls, coordinates issue remediation, and translates findings into clear actions for operational and senior leaders.
This leader sets team direction, prioritizes work, develops employees, resolves operational and quality issues, and adapts team plans to changing business needs. The role works across Claims Operations, Clinical Quality, Compliance, Program Integrity, Analytics, Training, technology partners, and external claims partners to improve accuracy, reduce risk, maintain audit readiness, and support reliable claims outcomes.
This position is full-time, Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 5:00 pm CST. It may be necessary, given the business need, to work occasional overtime.
We offer 6 weeks of on-the-job training. The hours during training will be 8:00 am to 5:00 pm CST, Monday - Friday. Training will be conducted virtually from your home.
Primary Responsibilities:

• Lead and manage the Claims Quality team, including setting priorities, allocating workload, monitoring performance and capacity, coaching employees, supporting development, and ensuring appropriate operational coverage.
• Oversee Claims Quality activities across Medical, Dental, and Pharmacy Claims, including quality audits, sampling, findings, trends, follow-up, and overall audit performance.
• Lead internal and external audit calibration and quality-governance activities, promoting consistent audit methodology, scoring, interpretation, and resolution of identified discrepancies.
• Monitor Claims Quality performance and analyze audit findings, defects, trends, and operational data to identify risks, recurring issues, improvement opportunities, and recommended actions.
• Lead quality issue management and corrective-action activities, including root-cause analysis, remediation planning, escalation, follow-up, and effectiveness monitoring.
• Develop and strengthen operational and quality controls by identifying control gaps, monitoring risks, establishing appropriate oversight, and supporting audit and compliance readiness.
• Oversee Claims Quality reporting and governance, translating quality metrics, audit results, controls, risks, and operational issues into clear recommendations and executive-level information.
• Lead continuous-improvement initiatives to improve claims accuracy, reduce defects and rework, strengthen processes and controls, and improve operational effectiveness.
• Partner cross-functionally with Claims Operations, Clinical Quality, Compliance, Program Integrity, Analytics, Training, technology teams, and external partners to resolve issues and advance Claims Quality objectives.
• Maintain effective quality documentation and knowledge management, including work instructions, process documentation, training resources, audit evidence, and controlled records.
• Addresses special (ad - hoc) projects as appropriate; Performs special project audits and reviews as requested by other departments/regions.

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 OR equivalent work experience
• Must be 18 years of age OR older
• 3+ years of healthcare claims experience involving Medical, Dental, Pharmacy, or comparable claims operations
• 2+ years of people-leadership experience, including direct-report management, SME, or formal team-lead responsibility for workload, performance, coaching, development, and coverage
• 2+ years of quality assurance, claims auditing, compliance monitoring, or operational quality experience
• 2+ years of experience leading or supporting claims audits, quality monitoring, calibration, Audit-the-Auditor, error trending, or remediation
• 2+ years of experience identifying quality or operational issues and coordinating root-cause analysis, corrective actions, and follow-up
• 2+ years of experience using performance metrics, audit findings, or operational data to identify trends and recommend actions
• 1+ years of experience working across Operations, Quality, Compliance, Analytics, Clinical, or other cross-functional stakeholders
• Intermediate proficiency with Microsoft Excel, including filtering, sorting, pivot tables, charts, and analysis of structured data
• Proficiency with Microsoft Word, PowerPoint, Teams, and SharePoint
• Ability to work full-time, Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 5:00 pm CST. It may be necessary, given the business need, to work occasional overtime

Preferred Qualifications:

• Experience managing Claims Quality, healthcare quality, claims audit, or operational quality team
• Experience across more than one claims domain, such as Medical, Dental, or Pharmacy Claims
• Experience supporting government healthcare programs, government contracts, Veterans Affairs programs, or another highly regulated healthcare environment
• Experience developing or maintaining quality dashboards, governance scorecards, control inventories, control matrices, risk registers, or monitoring frameworks
• Experience with ServiceNow, Smartsheet, claims audit platforms, or comparable workflow and issue-management tools
• Experience with process mapping, business requirements, change management, audit readiness, or business continuity planning
• Working knowledge of healthcare claims concepts such as eligibility, provider validation, billing, coding, modifiers, duplicate claims, denials, routing, aging, and payment accuracy
• Lean Six Sigma, or comparable quality, process-improvement, project-management, audit, or healthcare certification

Telecommuting Requirements:

• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy.
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.

Soft Skills:

• Demonstrated ability to manage competing priorities, meet deadlines, communicate risk, and maintain accurate documentation

*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 $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
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 help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives.
UnitedHealth Group and its affiliated brands are 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 and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.