(RN) Manager - Utilization Management - 142006

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

Benefits offered by this job

Hybrid schedule

Job summary

UC San Diego Health IPA seeks a Manager of Utilization Management to lead nurse case management and referral coordination for commercial and Medicare Advantage plans. The role focuses on inpatient UM within IPA/Health Plan settings, ensuring regulatory compliance and effective delegated UM operations.

The position requires RN licensure in California, 5+ years in UM/IPA environments, and strong leadership and data-analysis skills. Hybrid schedule with some in-office days.

Qualifications

• Bachelor's degree in nursing and California RN license.
• Minimum five years of relevant experience, including IPA/MSO or Health Plan/HMO exposure.
• Experience with Commercial and Medicare lines of business.
• Strong prior authorization review experience.
• Knowledge of DOFRs, Epic, MCG, and HMO delegation.

Responsibilities

• Oversee day-to-day UM operations and supervise staff.
• Coordinate case management with clinical and nonclinical teams.
• Analyze and report UM data and regulatory compliance.
• Collaborate on operational improvements and new processes.
• Coach staff, participate in hiring and performance decisions.
• Provide staff training and orientation on UM updates.
• Implement new methods, systems, and processes.

Skills

Leadership

Prior Authorization

Communication

Regulatory compliance

Team supervision

Education

Bachelor's degree in nursing

Tools

Epic

EPC

MCG

Job description

DESCRIPTION

The Manager of Utilization Management supervises Nurse Case Manager and Referral Coordinator staff responsible for managed care utilization management (UM) operations for commercial and Medicare Advantage members under UC San Diego Health IPA and its HMO Health Plans. This position focuses on inpatient utilization management within a managed care/IPA environment, including oversight of delegated UM functions and compliance with applicable regulatory requirements and health plan delegation standards.

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 utilization review (UR)/discharge planning. Escalates complex cases as needed for Medical Director review or to the Assistant Director of 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, delegated UM operations, 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).