Quality Assurance Nurse, RN - UM - Inpatient

Date: Dec 25, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5487 


Position Summary/Position


Under the direction of the UM Inpatient Manager, the UM Quality Assurance (QA) Nurse is responsible for ensuring the highest quality processes are performed by the UM Nursing staff.  The QA nurse will utilize quality auditing tools and assist the UM Inpatient Manager and UM Nurse Trainer in identifying training needs for the prior authorization nursing staff.

Major Functions (Duties and Responsibilities)


1. Responsible for ongoing Quality Assurance of UM nursing RN line staff team members   based on audit criteria approved by the Chief of Medical Services and nursing knowledge of care plans, medication reconciliation, and prevention of readmissions
2. Responsible for ongoing Quality Assurance of delegated UM nursing functions for contracted vendors as needed. 
3. Review and report audit findings with UM Management in order to support requirements of accuracy and productivity on a monthly basis.
4. Must be familiar with UM regulatory requirements from NCQA, DHCS, DMHC, CMS and any other regulatory agency, utilization of standardized, nationally recognized criteria as approved and accepted by the IEHP UM Subcommittee, UM business rules and medical management system navigation and documentation. 
5. In conjunction with the UM Nurse Trainer and UM Manager, formulate improved processes for accuracy and assist with the identification of training needs.
6. The UM Quality Assurance Nurse will also be responsible for assisting the UM registered nurses in the day to day functions as needed.
7. Work closely with Utilization Management Manager and Director to achieve IEHP Utilization Management goals and regulatory requirements. The UM QA Nurse will also be responsible for collaborating with departments and supervisors regarding the development, implementation, tracking and feedback components related to quality standards.
8. Work with UM Nurse Trainer to ensure staff development/training when areas for improvement are identified during QA process.

Supervisory Responsibilities

Leading: Self

Experience Qualifications


Three or more years of utilization management experience in a health care delivery setting. QA scores of 97% or higher for two consecutive years along with score of Exceeds 3 or higher under QA on annual evaluation for two consecutive years.

Preferred Experience


Experience in an HMO or experience in a Managed Care setting preferred. Experience in Excel preferred.

Education Qualifications


High school diploma or GED required.

Preferred Education


Bachelor’s degree in nursing or health care related field from an accredited institution preferred.

Professional Certification

Professional Licenses


Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required. 

Drivers License Required


Knowledge Requirement


Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements. ICD-9/10 and CPT coding. Knowledge of capitated managed care environment helpful.

Skills Requirement


Excellent communication and interpersonal skills. Strong organizational skills. Microcomputer skills, proficiency in Windows applications preferred. 

Abilities Requirement


Professional demeanor. Exhibits a high attention to detail in documenting UM referral reviews. Ability to work at a high level of speed while maintaining accuracy. Ability to work well with both physician and nursing staff.

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions


While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus. 

Physical Requirements

Hearing: One-on-One - FREQUENTLY
Communicate: Information/ideas verbally - FREQUENTLY
Near Visual Acuity - FREQUENTLY
Keyboarding: 10-Key - FREQUENTLY
Keyboarding: Touch-Screen - FREQUENTLY
Keyboarding: Traditional - FREQUENTLY
Regular contacts: co-workers, supervisor - FREQUENTLY
Understand and follow direction - FREQUENTLY
Regular and reliable attendance - FREQUENTLY


Starting Salary: $75,296.00  - $95,992.00  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles