Manager, Utilization Management - 113191
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#113191 Manager, Utilization ManagementInitial Review Date: Mon 1/17/2022
For the safety and well-being of the entire university community, the University of California requires, with few exceptions, that all students, faculty and staff be vaccinated against the COVID-19 virus and influenza before they will be allowed on campus or in a facility or office. For more information visit: Flu Vaccine Mandate / COVID Vaccine Policy
Special Selection Applicants: Apply by 12/17/2021. Eligible Special Selection clients should contact their Disability Counselor for assistance.
This position has the ability to work hybrid (on-site and remote).
The qualifications of this position have been slightly modified as of 1/10/2022.
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 HMO Health Plans.
* Oversees and coordinates department operations, schedules staff to ensure adequate coverage, resolves system issues, advises on work methods, functions as a resource and assists with complex cases and escalates issues.
* Coordinates and/or leads case management teams with a variety of clinical and nonclinical staff to review specific 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 quality of patient care, appeals and grievances, timely access, in network vendor relationships and adequacy, referrals, cost and utilization data, 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 across the spectrum of care coordination services.
* Evaluates subordinate staff 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.
* Implements new methods, systems, and processes.
* Other duties as assigned.
Bachelor's degree in nursing or related area, or equivalent combination of experience and training.
Registered Nurse in the state of California.
Five (5+) 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 and inpatient/concurrent review process.
Experience and proven success in ability to effectively supervise a team and to manage the complex workflow and multiple priorities involved with care coordination and case management.
Previous UM experience working for an IPA or MSO.
A thorough understanding of Health Plan delegation, financial responsibility and medical necessity for referral processing using evidenced-based tools.
- Must pass a criminal background check.
- Must pass a pre-employment physical, drug screen and TB test.
- Must be able to work various hours and locations based on business needs.
Job offer is contingent on successful engagement in the UC COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).
UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, the only Burn Center in the county, and and dozens of outpatient clinics. We invite you to join our team!
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