Utilization Management Nurse, LVN - 4/10 Weekend Shift (Remote)

Date: Nov 24, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 8301 


Position Summary/Position


Under the general direction of the Utilization Management Clinical Manager and Supervisor, and within the LVN scope of practice, the incumbent is responsible for working directly with Providers, contracted entities and vendors to ensure coordinated, continuous cost effective quality healthcare for IEHP Members.

Major Functions (Duties and Responsibilities)


1. Responsible for gathering of clinical documentation to assist the R.N. Letter Review Nurse and Medical Director with decision of prospective/pre-service, concurrent, or retrospective reviews based on clinical criteria for appropriateness of outpatient services and care.
2. Works collaboratively with the UM clinical team to ensure regulatory timeframes are upheld for authorization of concurrent, outpatient or ancillary services as per approved clinical criteria, including but not limited to, outpatient surgery, durable medical equipment, home health, etc.
3. Serves as a resource for IEHP Member and Provider Service departments for outpatient utilization management, referral, and continuity of care issues.
4. Works with Contracts Department to identify gaps in provider network.
5. Responsible for assisting with the letter of agreement process when referring to Members to out-of-network providers.
6. Responsible for timely and appropriate documentation in the medical management system.
7. Assist with identifying potential cases for Case Management, Disease Management, Health Education and/or quality of care issues and making appropriate referrals when needed. 
8. Assist with identifying alternate payer sources such as CCS, IRC, etc.
9. Responsible for working with Team Members to support the goals of the department and the vision of the organization.
10. Participate in LEAN activities.

Experience Qualifications


Two (2) or more years of utilization management experience in a health care delivery setting.

Preferred Experience


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

Education Qualifications


High school diploma or GED required.

Professional Certification

Professional Licenses


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

Drivers License Required

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

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. MediCal, Medicare and other state/federal Program & Regulations.

Skills Requirement


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

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 $61,422.40 and $78,312.00, 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