Supervisor, UM Clinical, LVN

Date: Jan 14, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 6454 

 

Position Summary/Position

 

Under the direction of the Utilization Management Clinical Manager, the Utilization Management Clinical Supervisor, LVN is responsible for assisting in the management of clinical operations for IEHP Outpatient UM Department. In this capacity, the Utilization Management Clinical Supervisor, LVN will assist in the coordination of medical activities that involve all outpatient UM-related functions.

Major Functions (Duties and Responsibilities)

 

1. Assist in the oversight of Utilization Management Nurses’ interactions within IEHP and externally.  Supervision and training of outpatient UM nurse review staff including monitoring performance standards and completing formal evaluations at least annually.
2. Provide leadership and supervision of day to day utilization review functions to ensure high quality, cost effective services to Members and compliance with regulatory requirements, including assisting with current workload when turn-around times may be in jeopardy.
3. Has a working knowledge of the financial aspects related to both facility and professional components for IEHP Direct Health Plan. Provides support and assistance to the staff when questions arise concerning covered services and contracted providers.
4. Communicate with Practitioners and Provider Relations Department to provide information and assistance, as needed.
5. Assist in monitoring strategies to ensure high quality services are delivered to IEHP practitioners.
6. Assist in reviewing network coverage and ensuring extensive network exists at all times. Collaborate with IEHP Team members to maintain network.
7. Interfacing with the UM Clinical Manager and UM Nurses to resolve issues and establish or refine policies and protocol for ensuring high customer service.
8. Serve as a resource to department team members, internal departments and external partners regarding prior authorization regulations and processes.
9. Assist in analyzing utilization and referral practices for trends and reviewing findings with UM Manager.
10. Responsible to assist the UM Manager in gathering UM statistical data, and checking for accuracy.
11. Assist in the development of internal and external Policy and Procedure Manuals including producing an IEHP Direct Reference Guide.
12. Providing open lines of communication with providers on issues related to IEHP UM policies and procedures.
13. Conduct team member performance evaluation for feedback and/or coaching/counseling corrective action meetings with the assistance of a Human Resource representative and the TOC Manager, up to and including termination.
14. Coach, evaluate and provide performance evaluation feedback to team members.
15. Assist with the planning, development and implementation of new UM software.

Supervisory Responsibilities

Leader: Administers Hires, Terminations, and Performance Reviews

Experience Qualifications

 

Three (3) or more years’ experience with medical groups and an in-depth knowledge of all aspects of managed care operations with extensive knowledge of HMO and IPA operations with an emphasis on Utilization and Case Management. Previous experience required, including knowledge of CMS, NCQA, state regulations, benefits interpretation Local and National Coverage Determinations.

Preferred Experience

Education Qualifications

 

High school diploma or GED required.

Preferred Education

 

Bachelor's degree from an accredited institution preferred.

Professional Certification

Professional Licenses

 

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

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement

Skills Requirement

 

Analytical skills, time management, and problem solving.  Microcomputer applications (Microsoft Word and Excel, Access required) for use in all aspects of an office environment. Excellent communication, interpersonal and organizational skills.

Abilities Requirement

 

Self-starter and a team player. Must have a high degree of patience.

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

 

Starting Salary: $66,040.00  - $84,219.20  

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