Utilization Management Behavioral Health Nurse, RN (Remote)

Date: Jan 19, 2023

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 8533 


Position Summary/Position


Under the direction of the Inpatient Review Nurse Manager and Supervisor, the incumbent will work with hospitals and IPAs, in collaboration with their assigned Team Center to initiate coordinated and continuous cost effective quality healthcare to ensure the continuity of the Member’s care needs are met timely and readmission prevention is anticipated for IEHP Members the incumbent is responsible for providing intervention services to help Members and their families cope with the psychiatric conditions that can accompany their medical condition or inhibit optimal recovery such as transition from inpatient psychiatric care to outpatient care and to promote better health and functioning in order for Members to make the most effective use of their own abilities.  The review and authorization of treatment plans and authorization requests submitted by contracted Behavioral Health treatment providers.  The Psychiatric RN will also provide case management for members who are hospitalized for psychiatric treatment and collaborate with other Care Managers (LCSWs) regarding psychiatric medication therapy.

Major Functions (Duties and Responsibilities)


1. Assessment of psychiatric and medical factors that may have an effect on health or recovery from illness for Members requesting or receiving behavioral health care.
2. Coordinate referrals to appropriate professional or community resources or community-based organizations.
3. Interact with care management staff, IPAs, outside vendors, provider offices, and other agencies for coordination of care. May require home or facility visits.
4. Assist Care Managers and inpatient review nurses with discharge planning needs to ensure appropriate management and continuity of care for the Members.
5. Responsible for the oversight of concurrent and retrospective reviews for medical necessity per evidenced based criteria, appropriateness of service either through telephonic review or clinical documentation submitted by respective facilities.
6. Responsible for conducting reviews to ensure that Member’s treatment plan is consistent with diagnosis(es), specifically initial review within 24 hours to ensure Member’s meet specified criteria for the respective admission.
7. Responsible for ensuring that the concurrent or retrospective review process includes referring cases that require clinical consultation with the Medical Director in a timely manner and per assigned rounds schedule.
8. Responsible for identifying outliers and preparing documentation as well as reports on potential quality of care issues as identified.
9. Responsible for timely completion of denials process per policy and for timely compliance and completion of documents as required by regulatory requirements.
10. Serve as the IEHP liaison between hospitals, IPAs, vendors, outside agencies, providers, Team Members, and IEHP departments to ensure effective communication and collaboration in an effort to meet the Members treatment plan and goals as well as to support the goals of the department as well as strategic priorities and vision of the organization.
11. Participate actively in Lean and Improvement Activities.

Experience Qualifications


Two (2) years or more of UM/CM experience in a behavioral health care setting with an emphasis on concurrent review and utilization management.

Education Qualifications


Associate’s degree in the field of Nursing from an accredited institution required.

Professional Licenses


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

Drivers License Required

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

Knowledge Requirement


Knowledge of community resources and ability to make recommendations about the best course of action. Knowledge of health plan benefits in order to make referrals to other agencies when needed. Clinical knowledge of how mental disorders and psychosocial stressors can impact health conditions. Provide Clinical guidelines for Care Managers regarding psychiatric medication treatment issues and demonstrate expertise in the treatment of severe and persistent mental illness.

Skills Requirement


Clinical assessment skills to review treatment plans and clinical information in order to make appropriate referrals for treatment. Effective Communicator. Critical Thinking Skills.

Abilities Requirement


Active Collaborator.

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.

A reasonable salary expectation is between $79,809.60 and $101,774.40, based upon experience and internal equity.

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, designated as “Great Place to Work.” With a provider network of more than 5,000 and a team of more than 3,000 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and 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 stellar benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.

Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles