RN Telehealth Full-time
Inland Empire Health Plan

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

Inland Empire Health Plan Rancho Cucamonga, CA 91730, US
$91,249.60 - $120,910.40 / year
Overview:

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!

 

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 escalate 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.

Additional Benefits:

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
Key Responsibilities:
  1. Track inventory, workloads, and staff compliance with prior authorization requests
  2. Conduct quality audits of tools completed by UM Nurses and review corrective action plans submitted by the delegates
  3. Partner with the UM Clinical Regulatory leadership to review findings and implement necessary improvements.
  4. Serve as the primary point of contact for IPA’s and Delegates who are placed in concurrent review
  5. Disseminate approval or rejection of concurrent review files with a detailed explanation to the IPA/Delegate of corrections that are required for file(s) to pass
  6. Support UM Nurses by conducting secondary reviews of denial files for potential overturn due to medical necessity and escalate for medical director review
  7. Demonstrate advanced knowledge of all processes, systems, regulations, and compliance standards.
  8. Monitor all specific departmental standards, regulatory standards, and processes
  9. Collaborate with leadership to evaluate outcomes of the established processes, analyze gaps, and escalate to the supervisors/management team
  10. Provide support to leadership in evaluating UM Regulatory & Compliance metrics within the team and its’ downstream and upstream effects within the department
  11. Adhere and monitor processes established by any Lean events
  12. Raise any inconsistencies to the leadership management team
  13. Participate in development of new processes through LEAN participation
  14. Communicate any new processes and ensure adherence within the team
  15. Identify training gaps and collaborate with the training team for ongoing training needs
  16. Partner with Quality Assurance to identify gaps in knowledge
  17. Participate in problem solving gaps within the teams and within the department
  18. Partner in creating appropriate and efficient workflows, provide feedback in development of Job Aid, assist in validating the workflows
  19. Ensure continuous learning in a team or individual environment to build and maintain knowledge of all IEHP LOBs, products, and system requirements
  20. Perform any other duties as required to ensure Health Plan operations and department business needs are successful
Qualifications:

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

 

 

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

Work Model Location:

This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA)

Pay Range: USD $91,249.60 - USD $120,910.40 /Yr.

Share this job

Share to FB Share to LinkedIn Share to Twitter

Related Jobs

RN Infusion Outpatient Per Diem
Kaiser Permanente

Level III Staff RN - Anaheim - Infusion - Per Diem (0) - 8:00 AM - 4:30 PM

Kaiser Permanente Anaheim, CA
$74.50 - $102.22 / hour
Job Summary: As the leader of the health care team, provides professional nursing care, utilizing the nursing process in accordance with established standards of care, policies, and procedures. Demonstrates performance consistent with the Medical Center Vision, Mission, and Strategic Plan of the organization. Remains flexible to changing systems; is expected to demonstrate quality and effectiveness in work habits and clinical practice; and treats co-workers, patients, families, and all members of the health care team with dignity and respect. Essential Responsibilities: The Registered Nurse demonstrates proficiency by exhibiting the following skills, competencies, and behaviors: Leadership: Upholds Kaiser Permanentes Policies and Procedures, Principles of Responsibilities, and applicable state, federal and local laws. Serves as a leader of the health care team; delegates tasks appropriately, and demonstrates appropriate accountability. Understands own and team members scope of practice and escalates issues as appropriate. Demonstrates professional, supportive behavior. Champions new ideas. Leads and directs others through the change process. Utilizes communication strategies including chain of command and issue escalation, which result in intended outcomes. Participates in problem identification and resolution. Mentors, orients, and coaches others in unit specific operations and patient care activities Shares responsibility and authority with subordinates and holds him/her accountable for performance. Demonstrates ability to problem solve with other departments in order to assist member problem resolution. Prioritizes, delegates, and supervises work assignments appropriately to ensure completion of patient care activities. Complies with regulatory requirements, policies, procedures, and standards of practice. Nursing Process: Develops and/or contributes to the individualized plan of care that reflects assessment, planning, implementing, and evaluating the outcomes of that plan. Ensures plan shows multidisciplinary planning, consultation, and education. Ensures plan is reflective of admission or outpatient database, on-going findings, age appropriate care, cultural specific needs, and appropriate acuity. Ensures plan is discussed with patient, family/significant others, and completed in a timely manner. Monitors the patients progress based on the plan. Revises plan on ongoing basis based on patient condition and evaluation of progress. Ensures care meets standards of practice. Ensures effective development and completion of discharge plan including discharge barriers and patient/family education. Ensures that patient clearly understands discharge instructions. In outpatient, identify barriers and needs for patient/family education that will facilitate the outpatient medical management plan. Ensures patient safety related but not limited to, medications and procedures utilizing the five rights; patient falls; decubitus prevention and prevention of nosocomial infections. Ensures optimal pain control and patient comfort; identifies and discusses patient anxieties, fears or concerns regarding patient condition, treatment or discharge. Ensures that patient understands medication purpose, side effects, and administration instructions in the hospital as well as at the time of discharge . Documentation: Charting is accurate, legible, dated, and timed. Documentation reflects nursing process and interventions and evaluations taken. Utilizes computer systems effectively and efficiently for optimal patient care. Clinical Outcomes: Discusses patient findings and progress toward outcomes with physicians and other members of the health care team. Demonstrates competencies during the probationary period and ongoing completion by departmental competency validation. Make comprehensive nursing decisions based on interpretation of data, assessments, and evaluations of patient outcomes. Participates in departmental performance improvement activities, i.e., planning, measuring/monitoring, assessing, and improving. Workplace Safety: Adherence to LMP Workplace Safety principles and practices. Applies standard precautions; maintains a safe environment for self and others Patient Care Experience: Practices customer service standards as defined by the Service Area, Medical Center, and specified department. Promptly answers call lights, alarms, and patient requests. Makes appropriate referrals and facilitates the customers ability to utilize resources. Maintains and protects patient confidentiality Ensures clean, orderly, and functional work environment. Treats all families of patients with courtesy, respect, kindness and compassion. Provides an optimal patient care experience by actively listening to the needs of patients and family members and taking responsibility for meeting those identified needs. Gives patients information in a way they can understand and ensures comprehension. Provides a patient care experience that exceeds members expectations. Team Commitment: Viewed by others to be an effective team member who is flexible, cooperative, and willing to assist others. Confronts difficult or conflict situations constructively and seeks appropriate assistance. Takes accountability for own actions and accepts constructive criticism. Acts as a resource, preceptor, and mentor to new employees, registry, students, and other team members. Attends all mandatory meetings, in-services and staff meetings as required, actively participates in other departmental professional development. (Requirement may vary for per diem staff). Participates with the assessment of current and future unit learning needs and development of an annual education plan. Keeps self informed of activities on the unit and makes recommendations for change. Adheres to Attendance Program. Reports to assigned area promptly, being present and available for report at beginning of assigned shift. Supports a collaborative Labor-Management Partnership environment through unit based teams. Fiscal Responsibility Organizes work to minimize the use of overtime. Identifies and assists in systems improvement that needs simplification or correction. Utilizes payroll and non-payroll resources to their maximum potential.
RN Outpatient Infusion Outpatient Per Diem
Kaiser Permanente

Level III Staff RN - Anaheim - Ambulatory Infusion - Per Diem (0) - 8:00 AM - 4:30 PM

Kaiser Permanente Anaheim, CA
Job Summary: As the leader of the health care team, provides professional nursing care, utilizing the nursing process in accordance with established standards of care, policies, and procedures. Demonstrates performance consistent with the Medical Center Vision, Mission, and Strategic Plan of the organization. Remains flexible to changing systems; is expected to demonstrate quality and effectiveness in work habits and clinical practice; and treats co-workers, patients, families, and all members of the health care team with dignity and respect. Essential Responsibilities: The Registered Nurse demonstrates proficiency by exhibiting the following skills, competencies, and behaviors: Leadership: Upholds Kaiser Permanentes Policies and Procedures, Principles of Responsibilities, and applicable state, federal and local laws. Serves as a leader of the health care team; delegates tasks appropriately, and demonstrates appropriate accountability. Understands own and team members scope of practice and escalates issues as appropriate. Demonstrates professional, supportive behavior. Champions new ideas. Leads and directs others through the change process. Utilizes communication strategies including chain of command and issue escalation, which result in intended outcomes. Participates in problem identification and resolution. Mentors, orients, and coaches others in unit specific operations and patient care activities Shares responsibility and authority with subordinates and holds him/her accountable for performance. Demonstrates ability to problem solve with other departments in order to assist member problem resolution. Prioritizes, delegates, and supervises work assignments appropriately to ensure completion of patient care activities. Complies with regulatory requirements, policies, procedures, and standards of practice. Nursing Process: Develops and/or contributes to the individualized plan of care that reflects assessment, planning, implementing, and evaluating the outcomes of that plan. Ensures plan shows multidisciplinary planning, consultation, and education. Ensures plan is reflective of admission or outpatient database, on-going findings, age appropriate care, cultural specific needs, and appropriate acuity. Ensures plan is discussed with patient, family/significant others, and completed in a timely manner. Monitors the patients progress based on the plan. Revises plan on ongoing basis based on patient condition and evaluation of progress. Ensures care meets standards of practice. Ensures effective development and completion of discharge plan including discharge barriers and patient/family education. Ensures that patient clearly understands discharge instructions. In outpatient, identify barriers and needs for patient/family education that will facilitate the outpatient medical management plan. Ensures patient safety related but not limited to, medications and procedures utilizing the five rights; patient falls; decubitus prevention and prevention of nosocomial infections. Ensures optimal pain control and patient comfort; identifies and discusses patient anxieties, fears or concerns regarding patient condition, treatment or discharge. Ensures that patient understands medication purpose, side effects, and administration instructions in the hospital as well as at the time of discharge . Documentation: Charting is accurate, legible, dated, and timed. Documentation reflects nursing process and interventions and evaluations taken. Utilizes computer systems effectively and efficiently for optimal patient care. Clinical Outcomes: Discusses patient findings and progress toward outcomes with physicians and other members of the health care team. Demonstrates competencies during the probationary period and ongoing completion by departmental competency validation. Make comprehensive nursing decisions based on interpretation of data, assessments, and evaluations of patient outcomes. Participates in departmental performance improvement activities, i.e., planning, measuring/monitoring, assessing, and improving. Workplace Safety: Adherence to LMP Workplace Safety principles and practices. Applies standard precautions; maintains a safe environment for self and others Patient Care Experience: Practices customer service standards as defined by the Service Area, Medical Center, and specified department. Promptly answers call lights, alarms, and patient requests. Makes appropriate referrals and facilitates the customers ability to utilize resources. Maintains and protects patient confidentiality Ensures clean, orderly, and functional work environment. Treats all families of patients with courtesy, respect, kindness and compassion. Provides an optimal patient care experience by actively listening to the needs of patients and family members and taking responsibility for meeting those identified needs. Gives patients information in a way they can understand and ensures comprehension. Provides a patient care experience that exceeds members expectations. Team Commitment: Viewed by others to be an effective team member who is flexible, cooperative, and willing to assist others. Confronts difficult or conflict situations constructively and seeks appropriate assistance. Takes accountability for own actions and accepts constructive criticism. Acts as a resource, preceptor, and mentor to new employees, registry, students, and other team members. Attends all mandatory meetings, in-services and staff meetings as required, actively participates in other departmental professional development. (Requirement may vary for per diem staff). Participates with the assessment of current and future unit learning needs and development of an annual education plan. Keeps self informed of activities on the unit and makes recommendations for change. Adheres to Attendance Program. Reports to assigned area promptly, being present and available for report at beginning of assigned shift. Supports a collaborative Labor-Management Partnership environment through unit based teams. Fiscal Responsibility Organizes work to minimize the use of overtime. Identifies and assists in systems improvement that needs simplification or correction. Utilizes payroll and non-payroll resources to their maximum potential.
RN Infusion Outpatient Per Diem
Kaiser Permanente

Level III Staff RN - Anaheim - Infusion - Per Diem (0) - 11:00 AM - 7:30 PM

Kaiser Permanente Anaheim, CA
Job Summary: As the leader of the health care team, provides professional nursing care, utilizing the nursing process in accordance with established standards of care, policies, and procedures. Demonstrates performance consistent with the Medical Center Vision, Mission, and Strategic Plan of the organization. Remains flexible to changing systems; is expected to demonstrate quality and effectiveness in work habits and clinical practice; and treats co-workers, patients, families, and all members of the health care team with dignity and respect. Essential Responsibilities: The Registered Nurse demonstrates proficiency by exhibiting the following skills, competencies, and behaviors: Leadership: Upholds Kaiser Permanentes Policies and Procedures, Principles of Responsibilities, and applicable state, federal and local laws. Serves as a leader of the health care team; delegates tasks appropriately, and demonstrates appropriate accountability. Understands own and team members scope of practice and escalates issues as appropriate. Demonstrates professional, supportive behavior. Champions new ideas. Leads and directs others through the change process. Utilizes communication strategies including chain of command and issue escalation, which result in intended outcomes. Participates in problem identification and resolution. Mentors, orients, and coaches others in unit specific operations and patient care activities Shares responsibility and authority with subordinates and holds him/her accountable for performance. Demonstrates ability to problem solve with other departments in order to assist member problem resolution. Prioritizes, delegates, and supervises work assignments appropriately to ensure completion of patient care activities. Complies with regulatory requirements, policies, procedures, and standards of practice. Nursing Process: Develops and/or contributes to the individualized plan of care that reflects assessment, planning, implementing, and evaluating the outcomes of that plan. Ensures plan shows multidisciplinary planning, consultation, and education. Ensures plan is reflective of admission or outpatient database, on-going findings, age appropriate care, cultural specific needs, and appropriate acuity. Ensures plan is discussed with patient, family/significant others, and completed in a timely manner. Monitors the patients progress based on the plan. Revises plan on ongoing basis based on patient condition and evaluation of progress. Ensures care meets standards of practice. Ensures effective development and completion of discharge plan including discharge barriers and patient/family education. Ensures that patient clearly understands discharge instructions. In outpatient, identify barriers and needs for patient/family education that will facilitate the outpatient medical management plan. Ensures patient safety related but not limited to, medications and procedures utilizing the five rights; patient falls; decubitus prevention and prevention of nosocomial infections. Ensures optimal pain control and patient comfort; identifies and discusses patient anxieties, fears or concerns regarding patient condition, treatment or discharge. Ensures that patient understands medication purpose, side effects, and administration instructions in the hospital as well as at the time of discharge . Documentation: Charting is accurate, legible, dated, and timed. Documentation reflects nursing process and interventions and evaluations taken. Utilizes computer systems effectively and efficiently for optimal patient care. Clinical Outcomes: Discusses patient findings and progress toward outcomes with physicians and other members of the health care team. Demonstrates competencies during the probationary period and ongoing completion by departmental competency validation. Make comprehensive nursing decisions based on interpretation of data, assessments, and evaluations of patient outcomes. Participates in departmental performance improvement activities, i.e., planning, measuring/monitoring, assessing, and improving. Workplace Safety: Adherence to LMP Workplace Safety principles and practices. Applies standard precautions; maintains a safe environment for self and others Patient Care Experience: Practices customer service standards as defined by the Service Area, Medical Center, and specified department. Promptly answers call lights, alarms, and patient requests. Makes appropriate referrals and facilitates the customers ability to utilize resources. Maintains and protects patient confidentiality Ensures clean, orderly, and functional work environment. Treats all families of patients with courtesy, respect, kindness and compassion. Provides an optimal patient care experience by actively listening to the needs of patients and family members and taking responsibility for meeting those identified needs. Gives patients information in a way they can understand and ensures comprehension. Provides a patient care experience that exceeds members expectations. Team Commitment: Viewed by others to be an effective team member who is flexible, cooperative, and willing to assist others. Confronts difficult or conflict situations constructively and seeks appropriate assistance. Takes accountability for own actions and accepts constructive criticism. Acts as a resource, preceptor, and mentor to new employees, registry, students, and other team members. Attends all mandatory meetings, in-services and staff meetings as required, actively participates in other departmental professional development. (Requirement may vary for per diem staff). Participates with the assessment of current and future unit learning needs and development of an annual education plan. Keeps self informed of activities on the unit and makes recommendations for change. Adheres to Attendance Program. Reports to assigned area promptly, being present and available for report at beginning of assigned shift. Supports a collaborative Labor-Management Partnership environment through unit based teams. Fiscal Responsibility Organizes work to minimize the use of overtime. Identifies and assists in systems improvement that needs simplification or correction. Utilizes payroll and non-payroll resources to their maximum potential.
RN Infusion Full-time
Hydration Room

Registered Nurse (RN) - IV Infusion - Full-Time

Hydration Room Villa Park, CA
$48 - $58 / year
Help people thrive, while you're thriving too, in a setting built around balance, not burnout. $48/hour base pay. Guaranteed earnings up to $58/hour during your first six months through our Monthly Pay Guarantee Program. Imagine a nursing job where you have time to connect with your patients, take your lunch break, leave work on time, and focus on helping people feel their best instead of simply helping them survive the day. That's what we're building. Schedule: This is a full-time position. You will work 4-5 shifts per week (8 hours per shift), with 3 weekend shifts required per month. You will submit 4 days of unavailability per month. Locations You’ll Cover: Anaheim Hills, Brea, Yorba Linda, Villa Park, Fullerton and OC mobile IV shifts. What you'll do Administer IV vitamin therapy and injection treatments in a clean, modern wellness clinic. Build meaningful relationships with patients focused on proactive wellness. Lead and support your Wellness Coordinator team during each shift. Deliver an exceptional patient experience that naturally drives gratuities. Help shape the culture, workflow, and patient experience of a brand-new clinic. Why nurses choose Hydration Room $48/hour base pay. Guaranteed earnings up to $58/hour during your first six months through our Monthly Pay Guarantee Program. Unlimited earning potential after that. Many of our RNs earn an additional $15+/hour in tips. Be part of the opening team. Help build a new clinic instead of stepping into someone else's role. Predictable scheduling. Full-time, 4 to 5 shifts per week, 3 weekend shifts required per month. You will submit 4 days of unavailability per month. Paid time off. Medical, dental, vision, and life insurance for full-time employees. 401(k) for both full-time and part-time employees. Paid parental leave. Complimentary IV and injection treatments. Career growth opportunities, including Clinic Lead, District leadership, and future flagship locations. The details Schedule: Full-time. Clinic hours between 8:00 AM and 8:00 PM. Leave behind the hospital hustle and discover a more fulfilling path as a Registered Nurse (RN) at Hydration Room. This is your opportunity to maintain a healthy work-life balance while continuing to make a real difference with the skills you’ve worked hard to earn! What we're looking for Active California RN license in good standing. Current BLS certification. BSN or accredited nursing diploma. One year of related experience preferred A passion for delivering exceptional patient care and creating an outstanding patient experience. Physical Requirements: Prolonged periods sitting at a desk and working on a computer Must be able to traverse the entire facility Must be able to lift up to 15 pounds at times This job description indicates in general terms, the type and level of work performed as well as the typical responsibilities of employees in this classification. The duties described are not to be interpreted as being all inclusive or specific to any employee. The use of a particular expression or illustration describing duties shall not be held to exclude other duties not mentioned. This description is not intended to limit or in any way modify the right of any manager or supervisor to assign, direct, and control the work of employees. An ability to competently perform all the essential functions of the position (the combination of all essential duties and all essential skills and abilities listed above), with or without reasonable accommodation, is a basic requirement of all positions at the Hydration Room. The Hydration Room is an equal opportunity employer and will make reasonable accommodations in accordance with applicable law so that qualified employees can perform the essential functions of the job. Nothing in this job description changes the at-will employment relationship existing between the Hydration Room and its employees. The Hydration Room reserves the right to amend this job description at any time. #northoc
RN MDS Full-time
Epic Healthcare

MDS Nurse

Epic Healthcare City of Industry, CA
$38 - $40 / hour
Are you an experienced nurse with a strong understanding of MDS assessments and care planning ? Join our team and play an important role in ensuring residents receive quality, individualized care. Responsibilities: Complete and coordinate MDS assessments in accordance with applicable regulations and deadlines Develop and maintain accurate resident care plans for 45 clients in psych facility. Collaborate with nursing staff, physicians, therapy, dietary, and other interdisciplinary team members Monitor resident documentation for accuracy and completeness Participate in care plan meetings and ensure appropriate follow-up Maintain compliance with federal and state regulations Assist with accurate coding and documentation related to resident assessments Qualifications: Current LVN license in California Previous MDS experience required Knowledge of MDS/RAI requirements and long-term care regulations Strong organizational and communication skills Ability to work independently and meet assessment deadlines