Supervisor, UM Regulatory

4 weeks ago

Rancho Cucamonga, United States Inland Empire Health Plans 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.

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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