(RN) Manager - Utilization Management
The University of California, San Diego
About this position
Position Description
The Manager of Utilization Management supervises Nurse Case Manager and Referral Coordinator staff responsible for managed care utilization management (UM) operations for commercial and Medicare Advantage members under UC San Diego Health IPA and its HMO Health Plans. This position focuses on inpatient utilization management within a managed care/IPA environment, including oversight of delegated UM functions and compliance with applicable regulatory requirements and health plan delegation standards. 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 utilization review (UR)/discharge planning. Escalates complex cases as needed for Medical Director review or to the Assistant Director of 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, delegated UM operations, 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.
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 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. 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.