IEHP

Director

• Direct oversight of the Integrated Care Management teams.
• Lead health plan strategy that supports the integration of care management for all members on the continuum.
• Develop and implement a comprehensive care management program incorporating risk stratification, LTSS, population health management, and CalAim.
• Build strong rapport with executive teams from all clinical and non-clinical areas to execute business plans impacting the quality performance metrics and benchmarks of IEHP’s strategic goals.
• Collaborate with internal teams to design and implement the comprehensive and integrated care management model.
• Collaborate with external partners (County public health, County Behavioral Health, County care management programs such as MSSP, TCM, community-based organizations, hospitals, IPAs, ECM Providers) to develop a robust comprehensive and integrated care management model.
• Oversee the ECM model 1 program to ensure compliance in all DHCS ECM required regulations.
• Facilitate integration of care coordination, long term care, and behavioral health programs to ensure comprehensive care management.
• Lead/and or participate in work groups that will implement the new care management model for Medi-cal. These include but are not limited to in community supports, enhanced care management, long term support services, CCA, Dual Special Needs Plans, and population health.
• Collaborate with the quality oversight department across the various care management programs to oversight the department and delegates to ensure compliance with DHCS, DMHC, CMS, and NCQA.
• Develop Directors and Managers as leaders to ensure they have the tools and skill sets to execute their operational plans and act as role model for professional and clinical staff.
• Supervise and evaluate the Directors on an ongoing basis and provide support/feedback as needed.
• Actively participate in County, and/ or community work groups that are developing processes to integrate their model of care.
• Partner with community-based organizations to develop a broad network of services for our members and their communities that address social determinants of health.
• Participate in both counties homeless action planning, and behavioral health to develop programs to address the homeless crisis.
• Partner with both counties public health departments to develop strategies to address public health issues.
• Supervise work of others, including planning, assigning, scheduling, and reviewing work, ensuring quality standards.
• Responsible for hiring, terminating, training, and developing, reviewing performance, and administering corrective action for staff.
• Plan organizational structure and job content.
• Ensure that the programs and processes align to support the strategic goals of the organization and the care teams including external partners understand their roles and how they support organizational priorities.
• Develop the Annual Department Work Plan and quarterly updates that meet requirements for the annual QI Plan for all programs and ensure all indicators are met.
• Guide all Clinical/Operational processes, policies and procedures, and care management programs and utilize LEAN methodologies to promote efficiency.
• Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Senior Director, Integrated Care Management

Engineer

• Develop roadmap for middleware efforts including business initiatives, application upgrades, core infrastructure upgrades, middleware platform upgrades (Kafka, IIS, WebSphere, etc.) and compliance and regulatory items.
• Establish and include in roadmap compliance and operational items including functional and security patches, middleware managed server certificate refreshes, vulnerability remediation, platform upgrades and changes.
• Establish and include middleware improvements (e.g., log file rotation, automation) in the roadmap.
• Provide inputs for middleware backlog prioritization including, analysis and assessment of epics/stories, SWAG / estimates, identify dependencies and story sequencing and participate in feature deep-dive working sessions and meetings.
• Lead middleware requirements definition, provide middleware architecture and configuration expertise and details about middleware product capabilities.
• Provide technical leadership for middleware efforts - Middleware architecture, configuration, development, and deployment.
• Lead coordination middleware work effort with other teams.
• Implement, oversee, and ensure adherence to middleware controls.
• Technical ownership of middleware applications / products.
• Support BAU activities.
• Perform hands-on troubleshooting, optimization, performance tuning, installation, configuration, and design of large, complex enterprise environments based on industry best practices.
• Support middleware on multiple platforms.
• Investigates middleware and integration issues to provide resolutions and to develop root cause analyses for supporting maintenance improvements and upgrade planning.
• Manages middleware team tasks to meet project requirements.
• Perform production release of software updates/new functionality in partnership with IEHP’s AppDev teams.
• Perform system monitoring to ensure system operation health to meet service level agreements.
• Respond to service performance alerts and service interruptions to restore functionality and support customers.
• Perform capacity planning and performance tuning to prevent issues and minimize service interruptions.
• Interacts with system and storage teams to perform back-up and recovery procedures for ensuring business continuity.
• Write documentation to support middleware infrastructure.
• Maintain good communication with vendors, systems support teams, and local teams as needed; including interfacing with end users and next level management to provide technical consulting.
• Develop, enhance, debug, support, maintain, and test software applications and associated products.
• Participate in peer reviews for designs, code, and other work products.
• Provide 24 x 7 on-call support to ensure application functionality and to minimize disruptions.
• Monitor the IT Service Management System to resolve customer issues and meet service expectations.

Engineer III – Middleware

Manager

• The Behavioral Health Care Manager, SKI (Specialty Kids Intervention) BCBA is responsible for all aspects of services to IEHP members with autism, developmental disabilities, and/or intellectual disabilities and children with severe behavioral needs.
• The Behavioral Health Care Manager, SKI BCBA will also be responsible for reviewing requests for services, applying clinical criteria, applying clinical expertise to review treatment plans and authorizing services to ensure quality care coordination.
• This position ensures effective call support, case management as needed, care coordination as needed, and referral support.
• Under the direction of department leadership, the Behavioral Health Care Manager, SKI BCBA position works collaboratively with members of their own team, IEHP members and families, community agencies, and with the designated health care organization (HCO) medical team.
• This position is expected to model IEHP principles of relationship-based care, as well engage in promoting education and understanding of behavioral health and its importance in whole health, to those within IEHP and in the community.

Behavioral Health Care Manager, BCBA

Compliance

• Reporting to the Grievance & Appeals Regulatory Manager, the Grievance & Appeals Regulatory Nurse is responsible for working directly with providers, delegated entities, and internal IEHP departments in investigating and resolving cases, and responding to regulatory agencies to ensure compliance with internal Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations.
• This position coordinates member care in conjunction with the member’s Providers to provide continuous quality care and assist in the development of quality initiatives.
• The Grievance & Appeals Regulatory Nurse serves as a resource to IEHP personnel and providers.

Grievance & Appeals Regulatory Nurse

• Process all incoming DMHC, DHCS and CMS regulatory cases (Consumer Complaints, Independent Medical Reviews, statement of positions, CMS complaints, etc.) and monitoring timeliness of responses for all Plan lines of business.
• Act as a primary contact between IEHP and regulatory agencies in resolving Member grievance and appeals by maintaining positive communication and working closely with IEHP Compliance and Legal Departments in resolving Members’ complaints, grievances, and appeals.
• File Plan Grievances and Appeals / Claim Dispute / request State Fair Hearing process; distinguishing between an inquiry, a Grievance, an Appeal, a Claim Dispute, and a quality-of-care issue and know how to triage, resolve, or refer incoming calls/correspondence to appropriate personnel.
• Work closely with the Grievance and Appeals Team, with Internal Departments, and DMHC/DHCS/CMS to ensure all Member appeals are investigated, and care is coordinated appropriately.
• Process Plan level appeal and grievance cases as a result of a filed regulatory complaint.
• Review Member appeals and/or complaints and make appropriate determination based on documentation presented by appealing agent with references to federal, state, and local regulations as well as IEHP policy and procedures based on line of business in a timely manner.
• Manage all incoming court documents related to State Fair Hearing (SFH) cases, including preparing for scheduled SFH cases, preparation of witness (e.g., Medical Director) and arranging for appearance / telephonic requests of witnesses as well as exhibit gathering.
• Docket hearing notices, contact State / Office of Administrative hearings, establish duties and time frames in connection with each hearing and disseminate information with follow-up as appropriate.
• Support IEHP’s legal department as requested, to include participating in Plan Civil matters.
• Provide testimony on behalf of IEHP and administrative hearing and represent IEHP at hearings (virtual or in-person) when necessary and appropriate.
• Ensure Member appeals are fully investigated, to ensure timely and accurate decisions to either uphold or overturn denial using appropriate criteria hierarchy and work closely with Medical Director for approval.
• Ensure that written correspondence to Providers, Members, and regulatory entities is generated accurately and timely.
• Provide support to IEHP’s Civil Rights Coordinator with affiliated investigations both at the Plan level and for the Office of Civil Rights.
• Responsible for identifying potential cases that are high risk and using critical thinking to escalate to Manager and make appropriate decisions.
• Participate in LEAN initiatives using A3 thinking and LEAN concepts.
• Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Administration

• Lead planning, implementation, and ongoing management of Community Supports programs, ensuring alignment with CalAIM, DHCS APLs, contract requirements, and organizational strategy.
• Translate policy and regulatory guidance into operational workflows, job aids, and scalable program processes.
• Identify program risks, gaps, and opportunities; develop mitigation strategies and continuous improvement plans.
• Oversee day-to-day operations of assigned Community Supports programs, ensuring performance targets, service delivery standards, and timelines are met.
• Develop, maintain, and monitor program workflows, Standard Operating Procedures (SOPs), and operational tools.
• Partner with Finance, Claims, IT, Compliance, and Quality teams to ensure end-to-end operational integrity (referrals, authorizations, billing, reporting).
• Ensure appropriate escalation and resolution of complex operational issues.
• Serve as primary programmatic lead for Community Supports providers.
• Oversee provider onboarding, readiness, and ongoing monitoring activities.
• Collaborate with provider partners to improve performance, resolve operational challenges, and support compliance with contractual and regulatory requirements.
• Lead corrective action planning when performance, compliance, or quality issues are identified.
• Ensure Community Supports programs comply with applicable APLs, policy guidance, contracts, and audit requirements.
• Support internal and external audits, including documentation review, corrective actions, and response development.
• Partner with Compliance and Quality teams to develop monitoring tools and oversight frameworks.
• Maintain up-to-date knowledge of evolving state and federal requirements impacting Community Supports.
• Define and monitor KPIs, utilization trends, provider performance metrics, and member outcomes.
• Use data to drive program improvements, inform leadership decisions, and support reporting requirements.
• Prepare executive-level reports, dashboards, and presentations summarizing program performance and risks.
• Act as a key liaison with internal leaders, external partners, counties, and state agencies as needed.
• Lead cross-functional workgroups and meetings related to Community Supports initiatives.
• Communicate complex program information clearly to diverse audiences.
• Provide guidance, coaching, and mentorship to Program Managers and other team members.
• Lead special projects and enterprise-wide initiatives related to Community Supports.
• Contribute to team development, knowledge sharing, and best practice standardization.

Community Supports Program Administrator

Medical Director

• Identify clinical practice opportunities within business unit projects and activities and apply clinical and administrative skills to guide the department in implementing strategic, organizational and departmental improvements.
• Provide clinical leadership to implement, manage and achieve hospital and ancillary optimal care goals utilizing existing channels (i.e., Joint Operations Meetings, Inland Empire Alliance meetings, throughput and quality workgroups, etc.), and via development of new avenues for implementation of novel approaches to identified challenges and highlighting best practices.
• Develop relationships with internal and external clinical leadership teams and focuses on mutual goals to improve the quality of medical and ancillary services to advance optimal care (i.e., pediatric strategy, quality network implementation for hospitalist, hospice, post-acute services) and promote appropriate utilization of resources.
• Inform and educate hospital and ancillary clinicians about relevant changes in clinical best practices, regulatory mandates, and other relevant information to support the health plan’s strategies (i.e., palliative care initiatives, peer review program expectations).
• Maintain an updated and expanded knowledge base on factors that affect hospital and ancillary services, and ensures that relevant information about social, medical, and fiscal issues are incorporated into IEHP policies, procedures, and strategies (i.e., All-Plan Letters, state and federal regulations).
• Organize, coordinate, monitor, and promote the activities of the contracted medical providers to help ensure that the quality and appropriateness of services meets community standards. This may include collaboration with departmental leadership to educate and train clinicians in standards of care (i.e., specialty-specific care, evidenced-based practices, infection control practices, etc.).
• Provide recommendations for research and development activities in strengthening quality improvement efforts for the medical providers in hospital and ancillary areas. (i.e., Hospitalist Pay for Performance program).
• Articulate the importance and mission of the work surrounding hospice and post-acute services (i.e., SNF, long-term care, home health) to the community; specifically, how these impact hospital care quality and throughput, and Member/patient experience.
• Participate in the development and delivery of educational programs geared towards improving the practice of clinicians including, but not limited to, physicians, mid-level providers, etc. in various settings.
• Leverage knowledge of clinical, regulatory, social, political, and economic factors to provide feedback, as appropriate, to legislators and public policy makers about existing and proposed laws and regulations impacting hospital and ancillary care services. (i.e., payment practices).
• Monitor and improve quality of care delivered by medical providers rendering care to IEHP Members via a quality assessment and performance improvement program that encourages self-evaluation, anticipates, and plans for change, and meets regulatory requirements.
• Utilize results of quality assessment and performance improvement program findings to: a. Update and improve contracts, the medical provider evaluation process, financial incentives (i.e., pay for performance or value-based care integration), policies, procedures, and practices. b. Suggest, seek approval for and operationalize performance improvement activities aimed at closing gaps related to network adequacy, adequate utilization of available services (i.e., palliative care) and/or elevation of care delivery via innovative approaches. c. Identify solutions to problems that utilize a collaborative approach, including integration efforts with hospital, ancillary and community resources and services.
• Ensure, with other Medical Directors as appropriate, that Hospital and Ancillary Service Medical Staff and Contracted Medical Providers are providing appropriate care for IEHP Members including but not limited to availability of qualified medical consultative staff and oversight of their medical staff quality performance.
• Collaborate with Health Services to hold practitioners accountable for their utilization management activities (admissions, and transfers, including related orders and contracted facility case mix), engagement in interdisciplinary teams, performance, and practice, including corrective actions and adequate documentation of patient care as needed.
• Review recovery audit denials and appeals inclusive of second level appeal letter, second level medical necessity review, and peer to peer reviews.
• Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Medical Director – Hospital & Ancillary Relations

• Reporting to the Chief Quality Officer, the Director of Medicare Stars is responsible for leading the strategic direction, execution, regulatory compliance, and continuous performance improvement of the Medicare Star Ratings program at IEHP.
• This role will oversee enterprise-wide cross-functional initiatives to drive quality outcomes, enhance member experience, and ensure compliance with the Center of Medicare & Medicaid Services (CMS) Star Ratings requirements.
• The Director develops and implements data-driven strategies that improve performance across all Star measures in collaboration with clinical, operational, IT, and analytics team.
• By providing strategic oversight, fostering cross-functional collaboration, and leveraging data-driven insights, the Director will ensure IEHP not only meets, but exceeds CMS expectations enhancing quality outcomes, member experience, plan reputation, financial incentives, and driving sustainable growth.

Director, Medicare Stars

Recruitment

• Reporting to the Chief People Officer, the Director of Talent Acquisition is a cross-functional, highly collaborative role overseeing the Talent Acquisition team.
• Upholds IEHP’s Mission, Vision, and Values by growing and developing a comprehensive and candidate-centric talent function serving all levels of IEHP with a focus on talent sourcing and acquisition.
• Build an effective and inspired workforce while managing and providing services and best practices related to sourcing, recruitment, applicant tracking, selection, offer negotiation, hiring, and onboarding.
• Incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Senior Director, Integrated Care Management

Engineer III – Middleware

Behavioral Health Care Manager, BCBA

Grievance & Appeals Regulatory Nurse

Grievance & Appeals Regulatory Nurse

Community Supports Program Administrator

Medical Director – Hospital & Ancillary Relations

Director, Medicare Stars

Director, Talent Acquisition