IEHP

Nurse

• Lead coordination of complex or non-routine patient placements and discharges across facilities, service lines, and levels of care
• Serve as primary point of contact for escalated or complex cases, ensuring follow-up, resolution, and communication of placement status and decisions
• Facilitate transitions to higher or lower levels of care, including SNFs, CLHFs, and other post-acute settings
• Act as senior advisor and liaison between internal teams and external partners
• Review and assess clinical information to determine appropriate placement based on acuity, service needs, and facility capabilities
• Partner with case managers, social workers, providers, hospitals, IPAs, and post-acute partners to identify care pathways and resolve placement barriers
• Monitor patient movement and throughput, addressing delays and initiating escalation pathways
• Review program referrals, assign cases to Non-Routine Placement Specialists, and provide clinical oversight
• Provide education and guidance on complex placements and discharge coordination
• Maintain placement logs, referral tracking tools, and electronic medical records
• Document and track barriers, challenges, and interventions for reporting, audits, and quality improvement
• Ensure compliance with CMS, HEDIS, CAHPS, and other quality measures
• Participate in interdisciplinary huddles, throughput initiatives, and performance improvement activities
• Analyze trends, identify process gaps, and recommend workflow and care coordination improvements
• Support outreach and relationship-building with contracted providers and external partners
• Perform other duties required to support health plan operations and department needs

Non-Routine Placement Nurse, RN – Short-Term Assignment

Director

• Develop and execute enterprise pharmacy strategies across Medi-Cal, Medicare, and Exchange
• Collaborate with executive leadership to integrate pharmacy strategies into clinical care models, value-based initiatives, operations, quality, and clinical programs
• Lead initiatives to improve medication adherence, clinical outcomes, cost efficiency, and pharmacy quality performance
• Ensure compliance with CMS, DHCS, DMHC, and federal/state regulatory requirements
• Oversee pharmacy policy development and alignment with regulations and industry best practices
• Serve as the organization’s pharmacy compliance lead, ensuring audit readiness and regulatory deliverables
• Manage PBM and vendor relationships, including contract negotiation and performance programs
• Monitor formulary, rebate, and utilization management programs
• Ensure PBM performance metrics align with pricing strategy, member satisfaction, and health outcomes
• Direct pharmacy operations and clinical programs, including MTM, prior authorization, grievances and appeals, and performance measures
• Use data analytics to identify trends, cost drivers, and care improvement opportunities
• Drive access and affordability initiatives for vulnerable populations
• Establish and monitor productivity metrics
• Ensure adherence to departmental and organizational policies, procedures, and standards
• Partner with Quality, Provider Services, Case Management, Finance, and Actuarial on innovation and integrated care delivery
• Represent the pharmacy department in leadership forums, regulatory meetings, and industry engagements
• Hire, train, and manage support staff; monitor and evaluate outcomes
• Conduct performance reviews in accordance with IEHP guidelines
• Perform other duties required to support health plan operations and department needs

Senior Director, Pharmaceutical Services

Client Partner

• Partner with leaders to assess capability gaps and align learning strategies with enterprise goals
• Develop annual and multi-year learning plans for assigned business areas
• Ensure learning initiatives support performance, engagement, and culture objectives
• Serve as a trusted advisor to senior leaders and HR Business Partners
• Conduct needs assessments using performance consulting methodologies
• Diagnose root causes of performance gaps and recommend systemic solutions, including learning, process, structure, or leadership interventions
• Facilitate strategic conversations related to leadership development, team effectiveness, and change management
• Engage in the design process of evidence-based learning solutions using adult learning principles
• Incorporate modern learning technologies and analytics to enhance engagement and measure impact
• Facilitate high-impact leadership and team development sessions as needed
• Support organizational effectiveness initiatives, including team interventions, culture initiatives, leadership development frameworks, and change efforts
• Facilitate team sessions focused on alignment, accountability, communication, and performance
• Utilize assessments such as 360 feedback, personality, and engagement data to inform development strategies
• Partner on succession planning, individual development planning, and leadership readiness efforts
• Establish success metrics and evaluate the effectiveness of learning interventions
• Leverage engagement surveys, performance metrics, 9-box insights, and KPIs to refine strategies
• Continuously identify opportunities to enhance learning impact and business value
• Perform any other duties as required to ensure Health Plan operations and department business needs are successful

Learning & Development Partner

Supervisor

• Supervise, coordinate, and support implementation of Social and Community Services Programs
• Build and manage a high-performing team
• Plan, assign, schedule, and review team work while adhering to quality standards
• Hire, train, develop, conduct performance reviews, and administer corrective action when applicable
• Set professional goals and address barriers to members’ care
• Develop processes and workflows that improve member and team-member experience
• Support smooth transitions of care and member wellbeing
• Educate, coach, and support the SCS team in partnership with hospitals and providers
• Discuss complex cases, assist with escalated member needs, and recommend further action
• Develop agendas and lead monthly team meetings
• Track strategic goals, outcomes, KPI data, productivity, and HEDIS compliance contributions
• Communicate field intelligence to the SCS Manager
• Resolve service issues and represent Community Health and IEHP leadership
• Liaise with SCS teams, provider offices, and community-based organizations
• Nurture relationships with healthcare providers, community organizations, and stakeholder partners
• Work with providers, community organizations, and leaders to improve quality metrics and PHM Bold Goals 50x2025
• Attend and represent the SCS department at IEHP meetings and external events
• Coordinate special projects with the SCS Manager and community partners
• Share best practices, strengthen education and outreach, and promote care connections and disease prevention
• Conduct chart audits, quality assurance checks, coaching, clinical support, and shadowing
• Assist with closing complex and escalated member cases
• Facilitate regular case conferences
• Identify performance issues, care gaps, and operational efficiency opportunities
• Train team members on IEHP policies, regulations, procedures, workflows, and electronic medical management systems such as MedHok
• Monitor continuous quality improvement involving healthcare access, primary care, prevention, social determinants of health, and HEDIS gaps
• Implement the LEAN model for program standards, processes, and training
• Act on behalf of the Manager when needed
• Attend meetings, provide training, and perform next-level representation as required

Supervisor, Social and Community Service

Care Coordinator

• Monitor the Right Fax server, EDI Interface, and medical management system intake to ensure face sheets are processed timely
• Ensure hard-copy and electronic face sheets are complete and accurate with current Member demographic information
• Review daily census reports to eliminate duplicates and other unnecessary admissions
• Cover Cisco ACD Queue telephone lines and phone queues
• Check eligibility and assign authorizations to the appropriate ITC nurse using the Far tool
• Attach reviews and orders into the medical management system for ITC nurse review
• Review and approve service requests within the ITC Coordinator scope under the Utilization Management Guide
• Obtain Member discharge dates from facilities via calls, electronic medical records, or memo submissions
• Meet productivity, accuracy, and timely-processing standards for inpatient authorizations, service requests, and discharges
• Assist referral processes by requesting additional medical information from providers by phone, fax, or email
• Set up hospital follow-up appointments and provide information to Members; document calls in the medical management system
• Ensure Members receive ordered Home Health and Durable Medical Equipment items, documenting calls
• Process and coordinate disenrollment and transportation as needed
• Answer Utilization Management Department calls professionally on behalf of the Inland Empire Health Plan
• Communicate with providers and facilities regarding authorizations, orders, and clinical reviews in consultation with the ITC Nurse
• Assist the ITC Nurse with care management coordination for Members with identified care management conditions
• Collaborate on Member care issues and consult with ITC Nurses or ITC management to ensure appropriate treatment plans are followed
• Assist with identifying HEDIS gaps and conducting Member outreach
• Ensure documentation complies with regulatory requirements and accreditation standards
• Support Management or the Inpatient Clinical Team as requested
• Attend scheduled meetings
• Promote a positive and collaborative working environment within the CM Team

Coordinator – Integrated Transitional Care

Manager

• Work effectively with the Health Access Enhanced Care Management Care Coordination team, members and families, other professionals, and designated healthcare care organization medical teams
• Provide high-quality, effective care management to IEHP members
• Apply a person-centered model accounting for members’ medical, behavioral, and social needs
• Conduct outreach and engagement with members
• Engage members in skilled therapeutic interactions to promote health behaviors
• Provide behavioral health interventions within scope
• Coordinate care and link members to resources
• Work with professionals and community organizations to ensure quality of care
• Facilitate seamless transitions of care and the right care at the right time
• Provide clinical expertise, leadership, and oversight within the Enhanced Care Management program
• Promote behavioral health principles of relationship-based care and education within IEHP and the community
• Meet face to face with highest-risk/high-utilizer populations in the field, with member consent
• Support and engage members to promote positive health behaviors
• Collaborate with care-team members and external partners
• Incorporate IEHP Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation

Care Manager, RN – Health Access, ECM

QA Engineer

• Ensure the integrity of all data created and updated by Claims Processing staff
• Utilize quality auditing tools
• Identify training needs
• Define effective and efficient methods for accurate data entry and adjudication
• Incorporate IEHP’s Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation
• Work under the direction of the Claims Quality Assurance Manager and Supervisor

Claims Specialist – Quality Assurance I

Product Manager

• Lead development and management of IEHP’s Medicare/D-SNP products across the full product lifecycle
• Ensure product alignment with strategy, performance metrics, regulatory requirements, contractual and licensing requirements, accreditation standards, and business requirements
• Support product implementation and strategic initiatives supporting Medicare/D-SNP membership growth objectives
• Work with division and department leaders to design products using industry research, historical performance, stakeholder feedback, and market trends
• Apply in-depth knowledge of product benefits, coverage, and regulatory requirements
• Lead ideation, planning, and implementation of new or enhanced benefits, products, programs, and pilots
• Provide research and analysis to executives and leaders on the strategic direction of Medicare/D-SNP products
• Develop and manage product lifecycle activities and strategic initiatives
• Develop product roadmaps, define scope and prioritization, and collaborate cross-functionally in a matrixed environment
• Identify execution risks, manage project changes and scope, and recommend mitigation and contingency plans
• Lead annual product launches, partnering with sales, marketing, growth, retention teams, delegated vendors, and frontline staff
• Deliver benefit training, explain benefit design, and oversee development and distribution of member materials
• Direct creation of sales and marketing collateral, program talking points, product education, and configuration and benefit display requirements
• Develop training materials and conduct annual and ongoing product training
• Coordinate product modifications and updates with divisions and departments
• Cultivate cross-organizational relationships to assess and prioritize upstream and downstream impacts
• Build and oversee the product manager team and provide training and skills development
• Hire, train, manage, and evaluate support staff and conduct performance reviews
• Perform other duties required for successful health plan operations and department business needs

Director – Health Plan Product Management

Pharmacist

• Perform patient-specific medication reviews and develop recommendations using established medical treatment protocols and clinical practice guidelines
• Evaluate and adjudicate prior authorization requests for medical drugs
• Evaluate and review drug claims for clinical appropriateness
• Perform Comprehensive Medication Reviews in compliance with CMS standards and timelines
• Evaluate and develop medication adherence recommendations for members and prescribers
• Coordinate with members, prescribers, and pharmacies to ensure patients obtain medications and understand instructions
• Evaluate and develop patient-specific recommendations supporting pharmacy clinical quality priorities, including HEDIS, MCAS, and STARS measures
• Resolve medication and pharmacy issues triaged from the Member Services Call Center or other internal departments
• Assist with formulary implementation, management, and maintenance
• Communicate verbal and written clinical recommendations regarding medication use, adherence, therapy changes, and risks
• Initiate outbound calls to members and prescribers to explain clinical recommendations
• Serve as subject matter expert for regulatory and operational audits, projects, quality improvement enhancements, LEAN projects, and other IEHP initiatives
• Perform other duties assigned by Pharmacy Leadership

Clinical Pharmacist – Pharmaceutical Services

• Serve as a resource for IEHP members and providers for care management and care coordination
• Screen members for appropriate care management needs, document findings, and communicate with the care team using approved screening tools
• Contribute to the development and modification of Individualized Care Plans with RN Care Managers and Interdisciplinary Care Team members
• Educate members according to approved plans and materials
• Communicate unexpected results with RN Care Managers and other Interdisciplinary Care Team members
• Assist members with access, referrals, authorizations, and medical and behavioral health coordination issues
• Act as a member advocate
• Build and maintain working relationships with providers, community agencies, and internal colleagues through in-person, phone, email, and fax communication
• Use evidence-based communication strategies such as Motivational Interviewing to resolve conflicts and collaborate on member cases
• Engage members using evidence-based approaches to promote collaboration with medical and behavioral teams and increase member control over whole health
• Participate in continuous quality improvement initiatives, including identifying and addressing HEDIS gaps and testing practices to improve member health outcomes
• Perform other duties required to support Health Plan operations and department business needs

Care Manager, LVN

Compliance

• Ensure the Covered California line of business is administered in alignment with compliance and operational requirements
• Support the annual Covered California product renewal and implementation cycle
• Support operational and system enhancement projects
• Support product and project implementation
• Conduct quality assurance reviews for product-owned regulatory templates, member-facing materials, and product documentation
• Support cross-functional product implementation projects involving regulatory compliance, system enhancement, process development, and improvement
• Develop project scopes, goals, deliverables, detailed project plans, and comprehensive project documentation
• Monitor project plans, manage scope and schedule changes, communicate risks, and report or escalate project status and barriers
• Assess policies and standard procedures against new regulations to identify compliance and process gaps
• Define annual product renewal implementation requirements
• Plan and manage regulatory templates, materials, and product documents for submission
• Support cross-functional implementation projects impacting up to three departments
• Facilitate development and documentation of operational and regulatory requirements, process flows, standard work, and business requirements
• Perform analytical activities using initiative and organizational skills
• Perform other duties required to support Health Plan operations and department business needs

Analyst I – Product & Regulatory Operations

• Input, review and decision Medicare Part B and Medi-Cal requests for J codes, S code, Q codes, B codes and other medical benefits drugs/supplies
• Review requests based on UM logic and criteria including LCD, NCD, UM manual, MCG, MDX and other established criteria
• Perform technical/clinical review of authorizations involving drugs and utilization management, including authorization, chart notes and relevant clinical information
• Decide prior authorizations within compliance turnaround times and quality standards meeting regulatory requirements
• Meet departmental goals including turnaround, production expectations and quality metrics
• Support company goals and IEHP’s strategic priorities
• Communicate with doctors and pharmacies regarding IEHP RxUM policies and procedures
• Interface with IEHP’s pharmacy benefit management company regarding adjudication and medication processing issues
• Assist with expedited discharge-related reviews and coordinate with specialty pharmacy providers and internal departments
• Assist the Clinical Pharmacist in reviewing members’ medication regimens and care coordination
• Participate in quality improvement enhancements, LEAN projects and managing for daily improvement
• Participate in pharmacy projects supporting HEDIS and CAHPS standards
• Participate in team training and professional development related to prior authorization processing, pharmacy claims, grievances, discharges and pharmacy issues
• Perform other duties required for successful health plan operations
• Ensure privacy and security of protected health information in accordance with HIPAA policies and procedures

Pharmacy Technician

• Perform patient-specific medication reviews and develop recommendations using established medical treatment protocols and clinical practice guidelines
• Evaluate and adjudicate prior authorization requests for medical drugs
• Evaluate and review drug claims for clinical appropriateness
• Perform Comprehensive Medication Reviews (CMR) in compliance with CMS standards and timelines
• Evaluate and develop medication adherence recommendations to members and prescribers
• Coordinate with members, prescribers, and pharmacies to assure patients obtain medication and understand instructions for use
• Evaluate and develop patient-specific recommendations to support pharmacy clinical quality priorities, including HEDIS, MCAS, and STARS measures
• Resolve medication and pharmacy issues for members triaged to pharmacy
• Assist with formulary implementation, management, and maintenance
• Communicate verbal and written clinical recommendations to members, prescribers, and pharmacies
• Initiate outbound calls to members and prescribers to explain clinical recommendations
• Act as subject matter expert for internal and external regulatory and operational audits, projects, quality improvement process enhancements, LEAN projects, and other IEHP initiatives
• Perform other assigned duties supporting successful Health Plan operations

• Develop product portfolios for all IEHP lines of business: Covered California, Medicare Advantage, Dual-eligible Special Needs Plans (D-SNP), and Group products
• Manage the product development lifecycle
• Drive projects to conduct market analyses and provide research and analysis to executives and leaders
• Work collaboratively to articulate strategy recommendations and monitor key product metrics
• Support product implementation and strategic initiatives to meet membership growth objectives
• Design products using industry research, historical product performance, stakeholder feedback, and market trends
• Ensure products align with IEHP’s Mission, Core Values, Strategic Priorities, regulations, contractual and licensing requirements, accreditation, and departmental business requirements
• Lead ideation, planning, and implementation of new or enhanced benefits, products, programs, or pilots
• Develop, design, and manage product lifecycle activities and strategic initiatives
• Develop product roadmaps, define scope and prioritization, and collaborate cross-functionally on execution
• Identify execution risks, manage project changes and scope, and recommend mitigation and contingency plans
• Lead annual product launches, coordinating with sales, marketing, growth, retention teams, vendors, and frontline staff
• Deliver benefit training, explain benefit design, and oversee member materials and sales and marketing collateral
• Develop training materials and conduct annual and ongoing product training
• Coordinate product modifications and updates with divisions and departments
• Cultivate organization-wide relationships to identify, assess, and prioritize initiative impacts
• Build and oversee the product manager team; provide training and skills development
• Hire, train, and manage support staff; monitor outcomes and conduct performance reviews
• Perform other duties required to support Health Plan operations and department business needs

Director, Health Plan Product Management

Coach

• Coach leaders and facilitators in Gemba practices to improve transformation quality, problem solving, and sustained outcomes
• Provide feedback and guidance to ensure Gemba is conducted consistently and aligned with enterprise standards
• Support initiative intake assessment, triage, charter development, facilitation readiness, and transformation resource alignment
• Establish and reinforce STAR-aligned problem-solving approaches, leader-led improvement practices, and structured facilitation methods
• Develop and maintain transformation methodologies, facilitation frameworks, coaching tools, leader enablement resources, and problem-solving standards
• Establish and sustain industry-standard transformation practices, facilitation standards, coaching methodologies, and operational excellence approaches
• Advise STAR facilitators through coaching, facilitation support, intake consultation, and best-practice application
• Monitor adoption, problem-solving quality, and outcomes; identify patterns, capture lessons learned, and refine tools and engagement models
• Reinforce consistent application of enterprise transformation principles and continuous improvement practices
• Deliver education and targeted learning experiences to drive adoption and sustainment
• Synthesize cross-initiative insights and transformation trends to identify system improvement opportunities and inform strategic priorities
• Perform other duties required to support Health Plan operations and department needs
• Report to the Chief Transformation Officer and partner with STAR leadership, leaders, sponsors, and facilitators

Non-Routine Placement Nurse, RN – Short-Term Assignment

Senior Director, Pharmaceutical Services

Learning & Development Partner

Supervisor, Social and Community Service

Coordinator – Integrated Transitional Care

Care Manager, RN – Health Access, ECM

Claims Specialist – Quality Assurance I

Director – Health Plan Product Management

Clinical Pharmacist – Pharmaceutical Services

Care Manager, LVN

Analyst I – Product & Regulatory Operations

Pharmacy Technician

Clinical Pharmacist – Pharmaceutical Services

Director, Health Plan Product Management

Transformation Gemba Coach