Supervisor, UM Regulatory

3 weeks ago

Rancho Cucamonga CA United States Inland Empire Health Plan Full time
What You Can You 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

As the Supervisor, UM Regulatory & Compliance, you play a pivotal role in ensuring the success, productivity, and regulatory compliance for Prior Authorization process within Utilization Management Out-Patient Services. You lead quality audits, provide clinical oversight, and mentor the team to deliver high-quality, cost-effective services. Your dynamic role involves interpreting compliance requirements, collaborating with leaders, and actively participating in process enhancements and LEAN projects. It’s an exciting position where you drive excellence, navigate regulatory landscapes, and shape the future of efficient healthcare operations.

Major Functions (Duties and Responsibilities)

1. Conduct quality audits and review final recommendations provided by Utilization Management nurses and review reconsiderations submitted by Utilization Management leadership or corrective actions plans submitted by IEHP delegates.
2. Provide leadership and supervision of day-to-day utilization review functions to ensure high-quality, cost-effective services to Members, IEHP delegates, and vendors to ensure compliance with regulatory requirements, including assisting with current workload when turn-around times may be in jeopardy. Mentor and provide training and direction to the Utilization Management Out-Patient Services Team Members.
3. Provide oversight of authorizations being issued in the UM Module by RX and ITC Teams ensuring adherence to regulatory requirements.
4. Develop data collection methods needed to measure various indicators for quality improvement and review of training data.
5. Interpret compliance and regulatory requirements to ensure IEHP processes are operationalized and in compliance with all regulatory agencies.
6. Effectively train Utilization Management staff in prior authorization processes to include training to draft denial language prior to submitting for medical director review. Review Utilization Management data related to timely processing and mailing of denials and partial approvals for Letter Review team.
7. Assist in the development, implementation, and maintenance of effective quality audit tools for both clinical and non-clinical prior authorization Team Members, IEHP delegates, and contracted vendors.
8. Collaborate with other leaders using the UM Module to evaluate outcomes of established processes and training, analyze gaps and escalate to upper management.
9. Collaborate with Utilization Management leadership to update Utilization Management policies related to prior authorization processes and correspondence requirements.
10. Work closely with other departments to ensure timely and accurate response to information requests concerning quality assurance and prior authorization activities (e.g., timely processing of referrals and denials, information requests concerning delegates). Conduct regular quality assurance reviews to ensure Team Members are meeting their accuracy standards.
11. Attend prior authorization staff meetings and education trainings necessary to maintain current Utilization Management knowledge.
12. Oversee call center activities ensuring regulatory adherence to SLAs of Member calls, COC, OG, OD, and Provider redirection requests. Monitor UM call centers to ensure the service levels are at 80% or above with less than a 5% abandonment rate.
13. Provide guidance on regulatory requirements, compliance, and best practices for both clinical and non-clinical prior authorization Team Members, IEHP delegates, and contracted vendors.
14. Actively participate in internal quality improvement process enhancements, LEAN projects and managing for daily improvement (MDI).
15. Generate utilization management reports to track and trend productivity, compliance, quality, and inventory for the use in the MDI/RIE boards.
16. Assist with the planning, development, and implementation of new Utilization Management software.

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.
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 & Requirements

Three (3) or more years of experience in utilization management in a health care delivery setting with knowledge of all aspects of managed care operations with extensive knowledge of HMO and IPA operations with an emphasis in Utilization Management Supervisory/lead capacity experience required.
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. Training/mentoring newer Team Members.
Organizing a workgroup to drive the successful implementation of a major program or process.
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.
Candidate with an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians without a Bachelor’s degree will require six (6) years of additional relevant work experience.
Internal Candidates Only: In lieu of the required degree or clinical licensure, a minimum of five (5) years of IEHP work experience in Health Services division is required for this position. This experience is in addition to the minimum years listed in the Experience Requirements above.

Key Qualifications

Understanding and sensitivity to a multi-cultural environment and community. Extensive knowledge of:
Title 22, Title 10, DMHC, DHCS, NCQA, and CMS regulatory requirements specifically as they relate to UM/Health Plan correspondence.
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
ICD-10 and CPT coding capitated managed care environment helpful.

Start your journey towards a thriving future with IEHP and apply

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