UC San Diego Health
(RN) Manager, Utilization Management - 136750
UC San Diego Health, San Diego, California, United States, 92189
Overview
(RN) Manager, Utilization Management
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UC San Diego Health Job posting details include department, scheduling, and eligibility. The position oversees Manager of Utilization Management staff and is located at UCSf 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; acts as a resource and assists with prior authorizations and inpatient UR/discharge planning; escalates complex cases as needed for Medical Director review or Assistant Director UM/Director of PHSO. Coordinates and/or leads case management teams with clinical and nonclinical staff to review routine, expedited and complex cases; optimizes house guidelines and scope of practice; evaluates options for quality and efficiency in the referral determination process. Collects, analyzes, and reports data on UM processes and results, including in-network vendor relationships, 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; participates in decisions on hiring, salary actions, terminations, performance ratings, and other human resources matters. Supports professional development and facilitates access to ongoing training and staff development opportunities. Ensures adequate orientation, training, and mentoring of new staff; keeps staff and patient care teams informed of changes in processes, technology, regulations, and quality standards; provides guidance on UM updates to processes, procedures, and policies. Implements new methods, systems, and processes; performs 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, including 3–5 years in a direct supervisory/managerial role within IPA/MSO or Health Plan/HMO, with Commercial and Medicare lines of business. Strong hands-on experience with prior authorization review processes. Knowledge of DOFRs, MCG, Epic, Prior Authorizations, HMO delegation (commercial and Medicare Advantage), compliance, risk, appeals and grievances. Experience and proven ability to supervise a team and manage complex workflows and multiple priorities. Excellent verbal and written communication and influencing skills across all staff levels, physicians, patients, and external constituents. Solid technology skills with familiarity of programs (e.g., EPC, MCG) and ability to prioritize multiple tasks in a fast-paced environment. Preferred Qualifications
Previous UM experience in an IPA/MSO or Health Plan/HMO in a managerial/supervisor role. 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, with weekend/holiday availability as needed. Hybrid Schedule: onsite 1–2 days per week after orientation; additional onsite days may be required based on department needs. Pay Transparency
Annual Full Pay Range: $132,600 - $259,800 (prorated if appointment percentage
Factors in determining compensation include experience, skills, knowledge, education, licensure, and certifications, and other business needs. The posted Hiring Pay Scale is the budgeted range UC San Diego Health expects to pay for this position; the Annual Full Pay Range may be broader due to internal equity, budget, and applicable agreements. Equal Opportunity & Additional Information
The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration 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 Health is smoke and tobacco free. UC San Diego Health maintains a drug-free environment; drug screening may be conducted where permitted by law.
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(RN) Manager, Utilization Management
–
UC San Diego Health Job posting details include department, scheduling, and eligibility. The position oversees Manager of Utilization Management staff and is located at UCSf 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; acts as a resource and assists with prior authorizations and inpatient UR/discharge planning; escalates complex cases as needed for Medical Director review or Assistant Director UM/Director of PHSO. Coordinates and/or leads case management teams with clinical and nonclinical staff to review routine, expedited and complex cases; optimizes house guidelines and scope of practice; evaluates options for quality and efficiency in the referral determination process. Collects, analyzes, and reports data on UM processes and results, including in-network vendor relationships, 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; participates in decisions on hiring, salary actions, terminations, performance ratings, and other human resources matters. Supports professional development and facilitates access to ongoing training and staff development opportunities. Ensures adequate orientation, training, and mentoring of new staff; keeps staff and patient care teams informed of changes in processes, technology, regulations, and quality standards; provides guidance on UM updates to processes, procedures, and policies. Implements new methods, systems, and processes; performs 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, including 3–5 years in a direct supervisory/managerial role within IPA/MSO or Health Plan/HMO, with Commercial and Medicare lines of business. Strong hands-on experience with prior authorization review processes. Knowledge of DOFRs, MCG, Epic, Prior Authorizations, HMO delegation (commercial and Medicare Advantage), compliance, risk, appeals and grievances. Experience and proven ability to supervise a team and manage complex workflows and multiple priorities. Excellent verbal and written communication and influencing skills across all staff levels, physicians, patients, and external constituents. Solid technology skills with familiarity of programs (e.g., EPC, MCG) and ability to prioritize multiple tasks in a fast-paced environment. Preferred Qualifications
Previous UM experience in an IPA/MSO or Health Plan/HMO in a managerial/supervisor role. 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, with weekend/holiday availability as needed. Hybrid Schedule: onsite 1–2 days per week after orientation; additional onsite days may be required based on department needs. Pay Transparency
Annual Full Pay Range: $132,600 - $259,800 (prorated if appointment percentage
Factors in determining compensation include experience, skills, knowledge, education, licensure, and certifications, and other business needs. The posted Hiring Pay Scale is the budgeted range UC San Diego Health expects to pay for this position; the Annual Full Pay Range may be broader due to internal equity, budget, and applicable agreements. Equal Opportunity & Additional Information
The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration 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 Health is smoke and tobacco free. UC San Diego Health maintains a drug-free environment; drug screening may be conducted where permitted by law.
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