Team Lead - UM Regulatory & Compliance, RN (Remote)

Inland Empire Health Plan; Rancho Cucamonga (CA); Remote; USD 90,000 - 130,000; Full time

Benefits offered by this job

Competitive salary

State of the art fitness center on-<br

Medical Insurance with Dental and Vis

Life, short-term, and long-term disa

Career advancement opportunities and <

Wellness programs that promote a <

Flexible Spending Account – HealthCare

CalPERS retirement

457(b) option with a contribution m

Paid life insurance for employees

Pet care insurance

Job summary

Inland Empire Health Plan (IEHP) in Rancho Cucamonga is seeking a Team Lead - UM Regulatory & Compliance, RN to serve as the subject matter expert on prior authorization and letter reviews. You will be the first-line resource for clinical staff to ensure adherence to UM regulatory standards and LEAN initiatives.

You will collaborate with UM leadership to manage daily operations of clinical staff, oversee inventory, and help the QA team bridge gaps to maintain Plan standards.

Qualifications

• RN license in good standing is required.
• Three years minimum in clinical utilization management.
• Experience in an HMO or Managed Care setting preferred.
• Two or more years of direct clinical patient care in an acute facility.

Responsibilities

• Serve as SME on prior authorization and letter reviews.
• First-line resource for clinical staff to meet UM/regulatory standards.
• Collaborate with UM leadership to manage daily operations and staffing.
• Oversee inventory management and LEAN project alignment.
• Bridge gaps with QA and supervisors to ensure compliance.

Education

Associate’s degree in nursing

Bachelor’s degree in nursing

Job description

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to anauthentic experience!

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 elevate 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.

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

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 Coverage Determination, 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