At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us in making healthcare work better for everyone through people-led, responsible AI while Caring. Connecting. Growing together. The Health Services & Quality Director provides strategic leadership, direction, and oversight for the Health Services, Care Management, Utilization Management, and Clinical Quality functions for the Wisconsin Medicaid health plan. This role is accountable for ensuring high-quality, member-centered care while driving clinical excellence, regulatory compliance, quality performance, and population health outcomes across all Medicaid programs. Working in a highly matrixed environment, the Director develops and executes integrated clinical and quality strategies that improve member outcomes, support affordability goals, enhance provider performance, and ensure compliance with state, federal, NCQA and accreditation requirements. The role serves as a key leader within the health plan and collaborates closely with executive leadership, state agencies, providers, and enterprise partners to advance the organization's quality, service, and operational objectives. Populations include Badger Care, SSI, Childless Adults, Family Care and Family Care Partnership. If you are located in Wisconsin, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities: • Health Services Leadership • Provide strategic leadership and oversight for Health Services functions including Care Management, Disease Management, Utilization Management, and Transition of Care programs • Lead and develop multidisciplinary clinical teams, ensuring effective performance, engagement, and professional development • Establish departmental goals, monitor performance outcomes, and drive continuous improvement initiatives • Ensure clinical programs support the health and well-being of statewide Medicaid membership across multiple programs and populations • Collaborate with operational and clinical leaders to align health services strategies with organizational priorities and contractual requirements • Drive initiatives that improve member experience, access to care, care coordination, quality outcomes, and health equity • Quality Management & Improvement • Provide overall leadership for the health plan's Quality Management Program and Quality Improvement Program • Develop and execute comprehensive quality strategies aligned with state, federal, NCQA, and organizational requirements • Oversee the development, implementation, monitoring, and evaluation of annual quality work plans and performance improvement initiatives • Lead efforts to improve HEDIS, CAHPS, Healthcare Effectiveness Data and Information Set (HEDIS), and other quality performance measures • Direct interventions to identify and close gaps in care while improving clinical outcomes and member engagement • Establish quality targets and oversee action plans to achieve performance goals • Coordinate quality improvement activities across clinical, provider, pharmacy, behavioral health, network, compliance, and member experience functions • Regulatory & Accreditation Oversight • Ensure compliance with Medicaid contractual requirements, state and federal regulations, NCQA standards, and accreditation requirements • Oversee the preparation, maintenance, approval, and submission of quality program documentation, including: • Quality Program Description • Quality Work Plan • Annual Evaluation • Policies and Procedures • Performance Improvement Projects (PIPs) • State-required reports and submissions • Lead readiness activities and corrective action planning associated with audits, accreditation reviews, EQRO reviews, and state oversight activities • Maintain effective quality governance structures, including quality committees and reporting processes • Stakeholder & Provider Engagement • Develop and maintain strong relationships with state regulators, Medicaid agencies, External Quality Review Organizations (EQROs), providers, and community partners • Represent the health plan in quality and clinical discussions with state stakeholders and external partners • Collaborate with provider organizations to improve quality performance, member outcomes, and regulatory compliance • Serve as a strategic advisor and subject matter expert for quality and health services initiatives • Contribute to Request for Proposal (RFP) responses and support Medicaid procurement activities, particularly quality and clinical program sections • Leadership & Organizational Effectiveness • Build, mentor, coach, and develop high-performing clinical and quality teams • Foster a culture of accountability, collaboration, innovation, and continuous improvement • Lead organizational change efforts related to clinical operations and quality performance • Utilize data, analytics, and performance insights to identify opportunities and drive strategic decision-making • Present clinical and quality performance results to executive leadership, state agencies, and other key stakeholders 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.
Optum Home & Community Care is part of UnitedHealth Group and provides telephonic case management services to help members navigate the health care system and access support services. As an RN Case Manager, you would assess members' health status, identify gaps in treatment plans, establish care goals, coordinate with multidisciplinary teams including mental health clinicians, provide patient education and coaching, make referrals to community resources, and facilitate transitions between care settings—primarily through phone calls in a high-volume customer service environment.
