Senior Nurse Leader — Utilization Management

UC San Diego Health; San Diego (CA); On-site; USD 160,000 - 200,000; Full time

Job summary

UC San Diego Health seeks a Manager of Utilization Management to supervise Nurse Case Manager and Referral Coordinator staff handling UM operations for commercial and Medicare Advantage members within UC San Diego Health IPA and its HMO Health Plans.

This role focuses on inpatient utilization management in a managed care/IPA setting, incl. oversight of delegated UM functions and regulatory compliance. Strong leadership and prior authorization expertise are essential.

Qualifications

• Bachelor's degree in nursing and California RN licensure.
• Five+ years of relevant experience including 3–5 years in IPA/MSO or Health Plan/HMO.
• Experience with Commercial and Medicare lines of business.
• Strong prior authorization review experience.
• Knowledge of DOFRs, MCG, Epic, Prior Authorizations, HMO delegation, compliance, risk, appeals, and grievances.
• Proven ability to supervise a team and manage complex workflow and priorities.

Responsibilities

• Oversees day-to-day department operations, schedules staff, and covers team duties as needed.
• Escalates complex cases for Medical Director review or UP/Director when necessary.
• Leads case management with clinical and nonclinical staff across referral processes.
• Collects and reports data on UM processes, vendor relationships, and regulatory compliance.
• Works with management to develop new UM processes and programs.
• Coaches staff and participates in hiring, salary actions, and performance reviews.
• Ensures orientation and ongoing training for new staff; communicates policy updates.
• Implements new methods, systems, and processes.

Skills

Leadership / Supervisory experience

Prior authorization review

Communication skills

IPA/MSO knowledge

Epic / EHR familiarity

Regulatory/compliance knowledge

Education

Bachelor's degree in nursing

Registered Nurse (CA)

Tools

Epic

MCG

Job description

UC San Diego Health seeks a Manager of Utilization Management to supervise Nurse Case Manager and Referral Coordinator staff handling UM operations for commercial and Medicare Advantage members within UC San Diego Health IPA and its HMO Health Plans.

This role focuses on inpatient utilization management in a managed care/IPA setting, incl. oversight of delegated UM functions and regulatory compliance. Strong leadership and prior authorization expertise are essential.