OverviewWhat you can expect!
Reporting to the UM Regulatory & Compliance leadership, the Team Lead - UM Regulatory & Compliance, RN serves as a subject matter expert on prior authorization and letter review processes. This position acts as the first-line resource for clinical staff to ensure the department’s regulatory standards and LEAN project initiatives are met. The Utilization Management Team Lead, RN collaborates with UM leadership to manage daily operations of clinical staff, oversee inventory management, and ensure all staff meet the organization's expectations. The Utilization Management Team Lead, RN requires advanced knowledge and understanding of UM’s clinical operations for the IPA and Plan delegates, LEAN rapid improvement events and UM metrics in order to be able to speak of the processes, think critically of the gaps and escalate issues and concerns timely to management. The team lead will focus on ensuring that Plan standards are adhered to and assist Quality Assurance and supervisor to bridge the gaps.
Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.
Additional Benefits
Perks
IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more
- Competitive salary
- State of the art fitness center on-site
- Medical Insurance with Dental and Vision
- Life, short-term, and long-term disability options
- Career advancement opportunities and professional development
- Wellness programs that promote a healthy work-life balance
- Flexible Spending Account – Health Care/Childcare
- CalPERS retirement
- 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance
Key Responsibilities
Track inventory, workloads, and staff compliance with prior authorization requests
Conduct quality audits of tools completed by UM Nurses and review corrective action plans submitted by the delegates
Partner with the UM Clinical Regulatory leadership to review findings and implement necessary improvements.
Serve as the primary point of contact for IPA’s and Delegates who are placed in concurrent review
Disseminate approval or rejection of concurrent review files with a detailed explanation to the IPA/Delegate of corrections that are required for file(s) to pass
Support UM Nurses by conducting secondary reviews of denial files for potential overturn due to medical necessity and escalate for medical director review
Demonstrate advanced knowledge of all processes, systems, regulations, and compliance standards.
Monitor all specific departmental standards, regulatory standards, and processes
Collaborate with leadership to evaluate outcomes of the established processes, analyze gaps, and escalate to the supervisors/management team
Provide support to leadership in evaluating UM Regulatory & Compliance metrics within the team and its’ downstream and upstream effects within the department
Adhere and monitor processes established by any Lean events
Raise any inconsistencies to the leadership management team
Participate in development of new processes through LEAN participation
Communicate any new processes and ensure adherence within the team
Identify training gaps and collaborate with the training team for ongoing training needs
Partner with Quality Assurance to identify gaps in knowledge
Participate in problem solving gaps within the teams and within the department
Partner in creating appropriate and efficient workflows, provide feedback in development of Job Aid, assist in validating the workflows
Ensure continuous learning in a team or individual environment to build and maintain knowledge of all IEHP LOBs, products, and system requirements
Perform any other duties as required to ensure Health Plan operations and department business needs are successful
Qualifications
Education & Requirements
- Associate’s degree in nursing from an accredited institution required
- Bachelor’s degree in nursing from an accredited institution preferred
- A minimum of three (3) years of experience in clinical utilization management processes
- Experience in an HMO or experience in a Managed Care setting
- A minimum of two (2) years of direct, hands-on clinical patient care experience in an acute care facility utilizing an active RN license is required
- Bilingual (English/IEHP Threshold Language) - written and verbal skills preferred
- Commercial Plan Coverage preferred
- For internal candidates: preferably two (2) years of experience working in the UM unit
Key Qualifications
- Advanced knowledge and in-depth understanding of:
- UM policies and regulations and processes
- Nationally recognized criteria such as Medicare Local CoverageDetermination, Medicare National Coverage Determination, Milliman Care Guidelines, InterQual, and Apollo Managed Care Guidelines/Medical Review Criteria
- Title 22, Title 10, DMHC, DHCS, CMS, and state regulatory requirements specifically as they relate to UM/Health
- Plan correspondence
- Clinical nursing practice, standards of care, and medical terminology
- Medical necessity standards and benefit interpretation
- Bilingual (English/IEHP Threshold Language) is preferred
- Strong proficiency in:
- Clinical assessment and documentation skills. Skills in documenting UM referral reviews accurately
- Written and verbal skills
- Computer applications, including word processing, database, and spreadsheets
- Problem-solving skills
- Proficient in Microsoft Office Suite
- Abstracting and interpreting medical information from clinical records
- Interpersonal skills
- Demonstrated ability to:
- Express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly
- Manage caseload efficiently
- Set priorities and work at a high level of speed to be highly productive and work well under pressure
- Work independently or as a team member
- Exhibit a high attention to detail in writing and verbally
- Work well with physicians and nursing staff both internally and externally
Start your journey towards a thriving future with IEHP and apply TODAY!
Work Model Location
This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA)
Pay RangeUSD $91,249.60 - USD $120,910.40 /Yr.
