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

Inland Empire Health Plan•Rancho Cucamonga, CA

3d•Hybrid

About The Position

The Team Lead - UM Regulatory & Compliance, RN serves as a subject matter expert on prior authorization and letter review processes and as a first-line resource for clinical staff, helping ensure regulatory standards and LEAN project initiatives are met. Reporting to UM Regulatory & Compliance leadership, the role collaborates with UM leadership to manage daily clinical staff operations and inventory, and to ensure staff meet organizational expectations. The team lead applies advanced knowledge of utilization management clinical operations for IPA and Plan delegates, LEAN rapid improvement events, and UM metrics to evaluate processes, identify gaps, and escalate issues to management. The role supports adherence to Plan standards and works with Quality Assurance and supervisors to address gaps. The position also contributes to IEHP’s Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation. The position follows a hybrid work schedule: remote on Monday and Friday, and onsite Tuesday through Thursday in Rancho Cucamonga, California. The stated pay range is USD $91,249.60–$120,910.40 per year.

Requirements

Associate’s degree in nursing from an accredited institution.
At least three years of experience in clinical utilization management processes.
Experience in an HMO or managed care setting.
At least two years of direct, hands-on clinical patient care experience in an acute care facility using an active RN license.
Advanced knowledge of UM policies, regulations, and processes.
Knowledge of nationally recognized criteria, including Medicare Local Coverage Determination, Medicare National Coverage Determination, Milliman Care Guidelines, InterQual, and Apollo Managed Care Guidelines/Medical Review Criteria.
Knowledge of Title 22, Title 10, DMHC, DHCS, CMS, and state regulatory requirements as they relate to UM and Health Plan correspondence.
Knowledge of clinical nursing practice, standards of care, and medical terminology.
Knowledge of medical necessity standards and benefit interpretation.
Clinical assessment and documentation skills, including accurate documentation of UM referral reviews.
Written and verbal communication skills; computer skills with word processing, databases, and spreadsheets; and proficiency in Microsoft Office Suite.
Ability to abstract and interpret medical information from clinical records.
Problem-solving and interpersonal skills.
Ability to communicate information and detailed instructions accurately and quickly to the public and staff.
Ability to manage a caseload efficiently, set priorities, work productively under pressure, and maintain strong attention to detail.
Ability to work independently or as a team member and collaborate effectively with physicians and nursing staff internally and externally.

Nice To Haves

Bachelor’s degree in nursing from an accredited institution.
Bilingual English and an IEHP Threshold Language, with written and verbal skills.
Commercial Plan Coverage experience.
For internal candidates, preferably two years of experience working in the UM unit.

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 delegates.
Partner with UM Clinical Regulatory leadership to review findings and implement improvements.
Serve as the primary point of contact for IPAs and delegates placed in concurrent review.
Disseminate approval or rejection of concurrent review files and explain required corrections to the IPA or delegate.
Support UM Nurses by conducting secondary reviews of denial files for potential overturn based on medical necessity, and escalate cases for medical director review.
Demonstrate advanced knowledge of processes, systems, regulations, and compliance standards.
Monitor departmental standards, regulatory standards, and processes.
Work with leadership to evaluate process outcomes, analyze gaps, and escalate issues to supervisors or management.
Support leadership in evaluating UM Regulatory & Compliance metrics and their downstream and upstream effects within the department.
Adhere to and monitor processes established by LEAN events; raise inconsistencies to leadership.
Participate in developing new processes through LEAN participation, communicate new processes, and ensure team adherence.
Identify training gaps and collaborate with the training team on ongoing training needs.
Partner with Quality Assurance to identify knowledge gaps and help solve gaps within teams and the department.
Help create efficient workflows, provide feedback on Job Aid development, and assist with workflow validation.
Maintain continuous learning to build and maintain knowledge of IEHP lines of business, products, and system requirements.
Perform other duties as required to support Health Plan operations and department business needs.