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IEHP

Nonprofit public health plan for the Inland Empire

Team Lead – UM Regulatory & Compliance

Medical, Clinical & VeterinaryConfirmed live in the last 24 hours
Full-timeRancho Cucamonga, CA, USA$91.2k - $120.9k /yr

About the Job

Requirements

  • An associate’s degree in nursing from an accredited institution is required.
  • At least three years of experience in clinical utilization management processes are required.
  • Experience in an HMO or managed care setting is required.
  • At least two years of direct, hands-on clinical patient-care experience in an acute-care facility using an active registered nurse license are required.
  • Advanced knowledge and in-depth understanding of utilization management policies, regulations, and processes is required.
  • Advanced knowledge of nationally recognized criteria, including Medicare Local Coverage Determination, Medicare National Coverage Determination, Milliman Care Guidelines, InterQual, and Apollo Managed Care Guidelines/Medical Review Criteria, is required.
  • Advanced knowledge of Title 22, Title 10, DMHC, DHCS, CMS, and state regulatory requirements as they relate to utilization management and health-plan correspondence is required.
  • Advanced knowledge of clinical nursing practice, standards of care, medical terminology, medical necessity standards, and benefit interpretation is required.
  • Proficiency in clinical assessment and documentation, including accurate documentation of utilization management referral reviews, is required.
  • Proficiency with computer applications, including word processing, databases, and spreadsheets, and the Microsoft Office Suite is required.
  • Abstracting and interpreting medical information from clinical records is required.
  • Problem-solving skills and the ability to manage a caseload efficiently are required.
  • The ability to set priorities, maintain productivity under pressure, and work independently or as part of a team is required.
  • The ability to communicate detailed instructions accurately and quickly, pay close attention to detail in writing and verbally, and work effectively with physicians and nursing staff internally and externally is required.

Responsibilities

  • Track inventory, workloads, and staff compliance with prior authorization requests.
  • Conduct quality audits of tools completed by utilization management nurses and review corrective action plans submitted by delegates.
  • Partner with utilization management clinical regulatory leadership to review findings and implement necessary improvements.
  • Serve as the primary point of contact for IPAs and delegates placed in concurrent review.
  • Communicate approval or rejection of concurrent review files to IPAs or delegates, with detailed explanations of required corrections for files to pass.
  • Support utilization management nurses by conducting secondary reviews of denial files for potential overturn based on medical necessity and escalate cases for medical director review.
  • Demonstrate advanced knowledge of processes, systems, regulations, and compliance standards.
  • Monitor departmental standards, regulatory standards, and processes.
  • Collaborate with leadership to evaluate process outcomes, analyze gaps, and escalate issues to supervisors or management.
  • Support leadership in evaluating utilization management regulatory and compliance metrics and their downstream and upstream effects within the department.
  • Adhere to and monitor processes established by Lean events.
  • Raise inconsistencies with the leadership management team.
  • Participate in developing new processes through Lean activities.
  • Communicate new processes and ensure adherence within the team.
  • Identify training gaps and collaborate with the training team on ongoing training needs.
  • Partner with Quality Assurance to identify knowledge gaps.
  • Participate in resolving gaps within teams and across the department.
  • Partner in creating efficient workflows, provide feedback during job-aid development, and assist in validating workflows.
  • Maintain knowledge of IEHP lines of business, products, and system requirements through continuous team or individual learning.
  • Perform other duties required to support health-plan operations and department business needs.

Desired Qualifications

  • A bachelor’s degree in nursing from an accredited institution is preferred.
  • Bilingual English and an IEHP threshold language, with written and verbal proficiency, is preferred.
  • Commercial Plan Coverage experience is preferred.
  • For internal candidates, two years of experience working in the utilization management unit is preferred.

About the Company

IEHP

Nonprofit public health plan for the Inland Empire

IEHP is a nonprofit public health plan that connects residents of California's Riverside and San Bernardino counties with health coverage and care. It administers Medi-Cal coverage for eligible low-income residents, IEHP DualChoice for people with both Medicare and Medi-Cal, and IEHP Covered plans through Covered California. Members receive care through a network of doctors and other providers, with dedicated care teams for those who need extra support. Its community wellness centers run free fitness classes and health workshops, and it connects residents with food and housing resources. IEHP began operating in 1996 and is headquartered in Rancho Cucamonga, California.

Company size
1,001-5,000
Company stage
Not listed
Total funding
Not listed
Headquarters
Rancho Cucamonga, CA
Founded
1996

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