Team Lead – UM Regulatory & Compliance, RN

IEHP

. Serve as a subject matter expert on prior authorization and letter review processes .

Posted 11/7/2026full-timeRancho Cucamonga • California • United StatesSenior💰 $91,250 - $120,910 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical utilization management processes, regulatory compliance, and quality assurance within healthcare settings. Proficient in managing clinical operations, conducting audits, and implementing process improvements while ensuring adherence to standards and effective communication across teams.

Highest-signal resume keywords

Clinical Utilization ManagementRegulatory ComplianceQuality AuditsLEAN Process ImprovementBilingual Communication

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentDocumentation SkillsMedical Necessity StandardsBenefit InterpretationKnowledge of Medicare LCDKnowledge of Medicare NCDKnowledge of Milliman Care GuidelinesKnowledge of InterQualKnowledge of Apollo Managed Care GuidelinesKnowledge of Title 22

Soft Skills

Problem-Solving SkillsStrong Written SkillsStrong Verbal SkillsHigh Attention to DetailAbility to Work Under Pressure

Tools & Technologies

Microsoft Office SuiteWord Processing ApplicationsDatabasesSpreadsheets

Certifications & Qualifications

Active RN LicenseAssociate’s Degree in NursingBachelor’s Degree in Nursing (Preferred)

Industry Keywords

HMOManaged CareUM PoliciesDMHCDHCSCMSHealth Plan OperationsClinical Nursing PracticeMedical TerminologyIPAs

Tech Stack

Tools & technologies

Apollo

About the role

Key responsibilities & impact

Serve as a subject matter expert on prior authorization and letter review processes
Act as the first-line resource for clinical staff to ensure regulatory standards and LEAN initiatives are met
Manage daily operations of clinical staff with UM leadership
Oversee inventory management and staff compliance with prior authorization requests
Track inventory, workloads, and staff compliance
Conduct quality audits of tools completed by UM Nurses and review corrective action plans from delegates
Partner with UM Clinical Regulatory leadership to review findings and implement improvements
Serve as primary contact for IPAs and Delegates in concurrent review
Disseminate approval or rejection of concurrent review files and explain required corrections
Conduct secondary reviews of denial files for potential overturn based on medical necessity
Escalate cases for medical director review
Monitor departmental and regulatory standards and processes
Evaluate process outcomes, analyze gaps, and escalate issues to supervisors and management
Evaluate UM Regulatory & Compliance metrics and downstream/upstream departmental effects
Adhere to and monitor processes established through LEAN events
Participate in developing new processes through LEAN participation
Communicate new processes and ensure team adherence
Identify training gaps and collaborate with the training team
Partner with Quality Assurance to identify knowledge gaps
Participate in problem-solving across teams and the department
Help create efficient workflows and validate job aids and workflows
Maintain knowledge of IEHP lines of business, products, and system requirements
Perform other duties supporting Health Plan operations and department business needs

Requirements

What you’ll need

Associate’s degree in nursing from an accredited institution required
Bachelor’s degree in nursing from an accredited institution preferred
Minimum of three (3) years of experience in clinical utilization management processes
Experience in an HMO or Managed Care setting
Minimum of two (2) years of direct, hands-on clinical patient care experience in an acute care facility utilizing an active RN license required
Bilingual (English/IEHP Threshold Language) written and verbal skills preferred
Commercial Plan Coverage preferred
Advanced knowledge of UM policies, regulations, and processes
Knowledge of Medicare LCD, Medicare NCD, Milliman Care Guidelines, InterQual, and Apollo Managed Care Guidelines/Medical Review Criteria
Knowledge of Title 22, Title 10, DMHC, DHCS, CMS, and state regulatory requirements related to UM/Health Plan correspondence
Knowledge of clinical nursing practice, standards of care, and medical terminology
Knowledge of medical necessity standards and benefit interpretation
Strong clinical assessment and documentation skills
Strong written and verbal skills
Proficiency with computer applications, including word processing, databases, and spreadsheets
Problem-solving skills
Proficiency in Microsoft Office Suite
Ability to abstract and interpret medical information from clinical records
Ability to manage caseload efficiently, prioritize, work under pressure, and work independently or as a team member
High attention to detail
Ability to work effectively with physicians and nursing staff internally and externally

Benefits

Comp & perks

Competitive salary
State of the art fitness center on-site
Medical Insurance with Dental and Vision
Life, short-term, and long-term disability options
Career advancement opportunities and professional development
Wellness programs that promote a healthy work-life balance
Flexible Spending Account – Health Care/Childcare
CalPERS retirement
457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance
Hybrid work schedule (Mon & Fri remote, Tues–Thurs onsite)