(RN) Manager, Utilization Management

Special Selection Applicants : Apply by 10 / 6 / 2025. Eligible Special Selection clients should contact their Disability Counselor for assistance.

The qualifications of this position have been slightly modified as of 10 / 3 / 2025.

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

PREFERRED QUALIFICATIONS

SPECIAL CONDITIONS

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).