(RN) Manager - Utilization Management - 140306

UC San Diego Health; San Diego (CA); Hybrid; USD 137,000 - 268,000; Full time

Benefits offered by this job

Hybrid work schedule

Job summary

UC San Diego Health is seeking a Manager of Utilization Management in California to supervise Nurse Case Manager and Referral Coordinator staff for commercial and senior attributed IPA members.

The role oversees day-to-day UM operations, leads case reviews, analyzes data, and partners with leadership to improve UM systems. Hybrid schedule with in-office days is required, and professional development is encouraged.

Qualifications

• Bachelor's degree in nursing and CA RN license.
• Five+ years of relevant experience, including IPA/MSO or Health Plan/HMO.
• Experience with Commercial and Medicare lines of business.
• Strong prior authorization review experience and process knowledge.
• Knowledge of DOFRs, MCG, Epic, Prior Authorizations, and HMO delegation.
• Ability to supervise a team and manage multiple priorities with excellent communication.

Responsibilities

• Oversee day-to-day UM department operations and staffing.
• Lead case management teams to review routine, expedited, and complex cases.
• Collect, analyze, and report data on UM processes and outcomes.
• Collaborate with management to develop new UM processes and programs.
• Coach staff and participate in hiring, performance, and HR decisions.
• Ensure orientation, training, and ongoing staff development.
• Provide guidance on UM updates to processes and clinical guidelines.

Skills

Nurse leadership

Team supervision

Effective communication

Analytical skills

Education

Bachelor's degree in nursing

Tools

Epic

MCG

Job description

UCSD Layoff from Career Appointment: Apply by 07/01/2026 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor.

Reassignment Applicants: Eligible Reassignment clients should contact their Disability Counselor for assistance.

DESCRIPTION

The Manager of Utilization Management supervises Nurse Case Manager and Referral Coordinator staff responsible for Managed Care Utilization Management (UM), following regulatory and compliance as it relates to delegation for commercial and senior attributed members under UC San Diego Health IPA for our HMO Health Plans.

Key Responsibilities

• Oversees and coordinates day-to-day department operations, schedules staff to ensure adequate coverage, prioritizes UM team workload and assignments, covers team member duties as needed, resolves system issues, advises on work methods, functions as a resource, and assists with prior authorizations and Inpatient UR/ Discharge planning and escalates complex cases as needed for Medical Director review or Assistant Director UM/ Director of PHSO.
• Coordinates and/or leads case management teams with a variety of clinical and nonclinical staff to review specific routine, expedited, and complex cases, optimize house guidelines and scope of practice, and evaluate options for quality and efficiency along the referral determination process.
• Collects, analyzes, and reports data on UM processes and results, including in network vendor relationships and adequacy, referrals, resource management, and regulatory compliance.
• Collaborates with management on operational and performance issues and the development of new processes and programs to improve UM systems and processes.
• Coaches and evaluates team members and participates in decision-making on hiring, salary actions, terminations, performance ratings, and other human resources matters.
• Pursues professional development and facilitates access to ongoing training, staff development, and educational opportunities for subordinate staff.
• Ensures adequate orientation, training, and mentoring of new staff. Keeps staff and patient care teams informed of changes and updates in processes, technology, regulations, and quality standards. Provides guidance and instructions on UM updates to processes, procedures and clinical guidelines/policies.
• Implements new methods, systems, and processes.
• Other duties as assigned.

MINIMUM QUALIFICATIONS

• Bachelor's degree in nursing.
• Registered Nurse in the state of California.
• Five or more years of relevant experience; experience must include 3-5 years of experience within IPA/MSO or Health Plan/HMO.
• Experience with Commercial and Medicare lines of business.
• Strong hands-on experience with prior authorization review process.
• Knowledge of DOFRs, MCG, Epic, Prior Authorizations, HMO delegation (commercial and Medicare Advantage), compliance, risk, appeals, and grievances.
• Experience and proven success in ability to effectively supervise a team and managing the complex workflow and multiple priorities.
• Must have excellent skills to communicate and influence effectively with all levels of staff, physicians, patients, and external constituents, both verbally and in writing.
• Solid technology skills with ease of use of all programs (such as EPC, mcg) and an ability to prioritize multiple tasks in a fast-paced environment.

PREFERRED QUALIFICATIONS

• Previous UM experience working for an IPA/MSO or Health Plan/HMO in a managerial/supervisor role.
• Thorough understanding of Health Plan delegation, financial responsibility, and medical necessity for referral processing using evidence-based tools.

SPECIAL CONDITIONS

• Employment is subject to a criminal background check and a pre-employment physical.
• Must be able to work various hours and locations based on business needs. Availability weekend/holidays as needed
• Hybrid Schedule: The candidate selected will work in the office 1-2 days per week once you complete initial orientation. Additional onsite days may be required based on department and business needs.

Pay Transparency Act

Annual Full Pay Range: $136,600 - $267,600 (will be prorated if the appointment percentage is less than 100%)

Hourly Equivalent: $65.42 - $128.16

Factors in determining the appropriate compensation for a role include experience, skills, knowledge, abilities, education, licensure and certifications, and other business and organizational needs. The Hiring Pay Scale referenced in the job posting is the budgeted salary or hourly range that the University reasonably expects to pay for this position. The Annual Full Pay Range may be broader than what the University anticipates to pay for this position, based on internal equity, budget, and collective bargaining agreements (when applicable).