Supervisor, Um Clinical, Lvn - 4/10 Weekend Shift (Remote)

Position Summary/Position
Under the direction of the Manager, UM Clinical - Prior Authorization, 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 always exists. 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. Major Functions (Duties and Responsibilities) Cont Supervisory Responsibilities Leader: Administers Hires, Terminations, and Performance Reviews Experience Qualifications
Three (3) or more years of 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. Supervisory/lead capacity experience required. 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 Board of Vocational Nursing and Psychiatric Technicians 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.
Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval. All IEHP positions approved for telecommute or hybrid 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. Work Model Location Telecommute Physical Requirements Hearing: One-on-One - FREQUENTLY Communicate: Information/ideas verbally - FREQUENTLY Near Visual Acuity - FREQUENTLY Regular contacts: co-workers, supervisor - FREQUENTLY Memory - FREQUENTLY Understand and follow direction - FREQUENTLY Regular and reliable attendance - CONSTANTLY Keyboarding: 10-Key - FREQUENTLY Keyboarding: Touch-Screen - FREQUENTLY Keyboarding: Traditional - FREQUENTLY Sitting - CONSTANTLY Indoors - FREQUENTLY Lighting - CONSTANTLY
A reasonable salary expectation is between $91,000.00 and $116,022.40, 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.