Job Description

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!

Under the general direction of the Utilization Management Manager, the Utilization Management Nurse is responsible for prospective and concurrent/retrospective review of referrals ensuring regulatory requirements are being met as they relate to language readability and appropriate citation of criteria in Member correspondence. This position is responsible to ensure meeting Member’s needs using nationally recognized UM criteria.

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
• Telecommute schedule
• 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

Conduct prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of service and care including specialist, outpatient and ancillary services, outpatient surgery, durable medical equipment, home health, and any high dollar cases

Screen medical information provided and authorization requests for medical necessity and appropriateness, comparing the information to current criteria and discussing with Medical Directors

Conduct prospective and retrospective reviews of referral denials, denial letters, and logs to determine appropriateness of denial, possible alternative treatment, and evaluation for case management or quality of care issues

Collaborate with UM Medical Director on reviews and final determination

Draft denial language to ensure consistent application of standardized, nationally recognized UM criteria and appropriate use of denial language

Translate medical terminology into lay language and grading the reading level as appropriate

Work closely with Medical Directors to ensure consistent use of guidelines/criteria

Create and maintain a standardized matrix of denial language split by Line of Business for internal and external use

Partner in the letter of agreement process when referring members to out-of-network providers

Review and report quality review findings with UM Management in order to support requirements of accuracy and productivity on a monthly basis

Obtain additional medical necessity information and research issues to assist Medical Directors with benefit interpretation. Support the UM Team with benefit interpretation and understanding of UM policies and procedures

Provide support to Medical Directors with revisions to IEHP UM Subcommittee Guidelines to ensure appropriate interpretation of criteria

Attend staff meetings and education trainings necessary to maintain current nursing and UM knowledge

Participate actively in LEAN activates to support the goals of the Department

Assist with the utilization management section of the Medical Management audit, as well as focused referral and denial audits

Perform any other duties as required to ensure Health Plan operations and department business needs are successful

Qualifications

Education & Requirements

• 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.
• Experience in an HMO or experience in a Managed Care setting preferred
• High school diploma or GED required
• Bachelor's degree in nursing from an accredited institution preferred
• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required

Key Qualifications

• Strong knowledge and understanding of:
• Nationally recognized UM 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.
• Strong proficiency in the following areas:
• Clinical assessment and documentation skills. Skills in documenting UM referral reviews accurately.
• Communication skills (both written and verbal).
• Critical thinking skills.
• Abstracting and interpreting medical information from clinical records.
• 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.
• Exhibit a high attention to detail.
• Work at a high level of speed while maintaining accuracy.
• Work well with both physicians and nursing staff.

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

Work Model Location

Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership)

Pay Range

USD $91,249.60 - USD $120,910.40 /Yr.