(RN) Manager - Utilization Management - 140306

About the role

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.

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.
• 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.

Requirements

• 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.
• 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.

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.

Skills

• Effective communication and influence skills.
• Ability to manage complex workflows and multiple priorities.
• Hands-on experience with prior authorization review process.
• Knowledge of relevant regulatory and compliance standards.
• Strong leadership and coaching skills.
• Technical proficiency with relevant software and systems.

Benefits

Not specified.

Pay

Annual Full Pay Range: $132,600 - $259,800 (will be prorated if the appointment percentage is less than 100%).

Schedule

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.