Manager, UM Regulatory

4 weeks ago

Rancho Cucamonga, California, United States Inland Empire Health Plan Full time
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 an authentic experience


The Manager, UM Regulatory & Compliance - CCA is responsible for the coordination, implementation, and oversight of the IEHP's overall Utilization Management Out-Patient Operations departmental clinical and operational compliance with regulatory requirements and quality assurance initiatives related to utilization management out-patient activities (e.g., Prior Authorization, UM Call Center operations).

This position will also oversee delegate clinical and operational compliance with regulatory requirements and quality assurance initiatives related to utilization management out-patient activities.

This role is responsible for the oversight/generation of all Utilization Management preservice regulatory correspondence including delivery and content. This role will assist the Director, UM Operations with the implementation and revision of policies and standards. This role requires collaboration and communication with various departments that share Utilization Management functions. This role will inspire and influence the team towards cultural transformation of the department through continuous improvement.

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.
Hybrid schedule.
CalPERS retirement.
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 & Experience

Five (5) or more years of experience in utilization management in a health care delivery setting. Three (3) or more years of supervisory experience with project management and team building experience essential. Working experience with State and Federal requirements (DHCS, CMS, DMHC) and quality standards (NCQA). Supervision can include managing projects and leading the participants of the project to successful implementation. Experience with training/mentoring newer Team Members. Organizing a workgroup to drive the successful implementation of a major program or process. Experience with Commercial Plan Coverage required.
Bachelor's degree in related field from an accredited institution required.

Candidate with an active, unrestricted, and unencumbered Registered Nurse (RN) issued by the California BRN without a Bachelor's degree will require four (4) years of additional relevant work experience.

This experience is in addition to the minimum years listed in the Experience Requirements above.
Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.
Yes, must have a valid California Driver's license and valid automobile insurance.

Must qualify and maintain driving record to drive company vehicles based on IEHP insurance standards of no more than three (3) points.

Understanding and sensitivity to a multi-cultural environment and community.

Key Qualifications

State and federal requirements and regulations of CMS, DHCS, DMHC, and NCQA.


All aspects of managed care operations with extensive knowledge of HMO and IPA operations with an emphasis on Utilization/ Case Management and program development.

Commercial managed care coverage.

ICD-10 and CPT/HCPC codes.

Start your journey towards a thriving future with IEHP and apply TODAY

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