UC San Diego
(RN) Manager, Utilization Management - 136750
UC San Diego, San Diego, California, United States, 92189
Overview
6256 Greenwich Dr, San Diego, CA, 92122 RN Manager, Utilization Management. Filing Deadline: Fri 10/3/2025. Apply Now. UC San Diego values equity, diversity, and inclusion. If you are interested in being part of our team, possess the needed licensure and certifications, and feel that you have most of the qualifications and/or transferable skills for a job opening, we strongly encourage you to apply. Special Selection Applicants : Apply by 10/6/2025. Eligible Special Selection 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 seniors 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 in a direct supervisory/managerial role 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 to manage 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 evidenced-based tools. Special Conditions
Employment is subject to a criminal background check and 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: $132,600 - $259,800 (will be prorated if the appointment percentage is less than 100%) Hourly Equivalent: $63.51 - $124.43 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). Apply Now Special Instructions and Compliance
If employed by the University of California, you may be required to comply with vaccination requirements and other directives. Some life-support certifications (BLS, NRP, ACLS, etc.) require hands-on practice and in-person skills assessment; online-only certification is not acceptable. UC San Diego Health is an academic health system with multiple facilities and programs. For more information, please visit UC San Diego Principles of Community. The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law. UC San Diego is a smoke and tobacco free environment. Please visit smokefree.ucsd.edu for more information. UC San Diego Health maintains a marijuana and drug free environment. Employees may be subject to drug screening. Applications/Resumes are accepted for current job openings only. For full consideration on any job, applications must be received prior to the initial closing date. If a job has an extended deadline, applications/resumes will be considered during the extension period; however, a job may be filled before the extended date is reached. UC San Diego is an Equal Opportunity Employer.
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6256 Greenwich Dr, San Diego, CA, 92122 RN Manager, Utilization Management. Filing Deadline: Fri 10/3/2025. Apply Now. UC San Diego values equity, diversity, and inclusion. If you are interested in being part of our team, possess the needed licensure and certifications, and feel that you have most of the qualifications and/or transferable skills for a job opening, we strongly encourage you to apply. Special Selection Applicants : Apply by 10/6/2025. Eligible Special Selection 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 seniors 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 in a direct supervisory/managerial role 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 to manage 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 evidenced-based tools. Special Conditions
Employment is subject to a criminal background check and 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: $132,600 - $259,800 (will be prorated if the appointment percentage is less than 100%) Hourly Equivalent: $63.51 - $124.43 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). Apply Now Special Instructions and Compliance
If employed by the University of California, you may be required to comply with vaccination requirements and other directives. Some life-support certifications (BLS, NRP, ACLS, etc.) require hands-on practice and in-person skills assessment; online-only certification is not acceptable. UC San Diego Health is an academic health system with multiple facilities and programs. For more information, please visit UC San Diego Principles of Community. The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law. UC San Diego is a smoke and tobacco free environment. Please visit smokefree.ucsd.edu for more information. UC San Diego Health maintains a marijuana and drug free environment. Employees may be subject to drug screening. Applications/Resumes are accepted for current job openings only. For full consideration on any job, applications must be received prior to the initial closing date. If a job has an extended deadline, applications/resumes will be considered during the extension period; however, a job may be filled before the extended date is reached. UC San Diego is an Equal Opportunity Employer.
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