Lead Medication Referral UMand QM Specialist

About the role

The Lead Medication Referral Nurse, Utilization Management and Quality Monitoring Specialist assists with the oversight of daily operations and provides training and support to Medication Referral Coordinators. This role offers high-level, complex referral support and coordination to the manager, serving as a liaison between the Referral Department, requesting providers, and the Medication Referral team. The specialist acts as a subject matter expert to staff, assists with clinical staff development, and supports health plan audits and quality improvement reports.

Responsibilities

• Facilitate open communication during team meetings and model collaborative problem-solving.
• Provide guidance and serve as a resource to Referral Coordinators.
• Assist with coverage and training to support the daily operations of the departments.
• Support leadership by guiding referral staff in daily operations, coordinating staffing coverage, and offering input for performance reviews.
• Act as the primary resource for infusion/injection-related questions regarding the medication referral process, contracts, and benefits provider/member inquiries.
• Assist in developing education materials and training new employees.
• Participate in continuous quality improvement activities and audit evaluations.
• Track, prioritize, and respond to daily departmental requests to ensure timely resolution of UM/health plan audits.
• Assist management with the development of policies and procedures as required.
• Serve as a liaison with other departments to troubleshoot and resolve referral issues, escalating complex matters to management as needed.
• Track referral turnaround times and accuracy by providing oversight of daily workflow to minimize processing errors in accordance with regulations and protocols.
• Support leadership in maintaining a positive work environment by assisting with employee concerns and facilitating conflict resolution.
• Perform other duties as assigned.
• Demonstrate job knowledge to serve others effectively.
• Be accountable for your work.
• Exhibit appropriate body language and tone of voice.

Requirements

• Current California LVN license or Registered Pharmacy Technician (licensure) required.
• Minimum of 3 years of healthcare experience required.
• Minimum of 2 years of experience in Quality, Utilization Review, or Utilization Management departments with knowledge of Medicare and Managed Care rules required.
• Basic computer skills, including knowledge of Microsoft Word and Excel.
• Experience with EZ-Cap, Q Auth, and Next Gen is preferred.
• Exceptional communication, detail-oriented, critical thinking, and problem-solving skills.
• Excellent customer service and telephone etiquette.
• Bilingual preferred but not required.
• Ability to manage time effectively and reprioritize tasks to meet deadlines.

At the discretion of management, this position has the potential to be a full or hybrid telecommuting role.

Physical Demands

• Sitting: Approximately 70% of the day.
• Standing: Approximately 15% of the day.
• Walking: Approximately 15% of the day.
• Lifting: 0–20 lbs (charts, supplies) – approximately 10% of the day.
• Bending: Approximately >10% of the day.
• Kneeling: <20% of the day.
• Hearing/Visual Acuity: Adequate for use with computers, telephone, and/or cellphone – approximately 50% of the day.
• Computer Use: Highly technical work environment – must be able to work ≥6 hours/day using a keyboard, mouse, and monitor.
• Reaching: Above head 75 degrees – approximately 25% of the day.
• Hand Grip Dexterity: Approximately 40% of the day.