(RN) Manager, Utilization Management - Hybrid | University of California San Diego
University of California San Diego
Location
La Jolla, CA | United States
Job description
Special Selection Applicants : Apply by 2/14/2024. Eligible Special Selection clients should contact their Disability Counselor for assistance.
This position will work a hybrid schedule which includes a combination of working both onsite at Greenwich Dr. and remote.
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
- Bachelor's degree in nursing or related area, or equivalent combination of experience and training.
- Registered Nurse in the state of California.
- Five 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.
- Knowledge of DOFRs, MCG, Epic, Prior Authorizations and Utilization Review, HMO delegation (commercial and Medicare Advantage), compliance, risk, appeals and grievances.
- 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.
- 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.
PREFERRED QUALIFICATIONS
- Previous UM experience working for an IPA or MSO in a managerial/supervisor role
- Thorough 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. Availability weekend/holidays as needed
- Hybrid Schedule: The candidate selected will work in the office 1-2 days per week once you complete initial orientation.
Pay Transparency Act
Annual Full Pay Range: $112,100 - $216,500 (will be prorated if the appointment percentage is less than 100%)
Hourly Equivalent: $53.69 - $103.69
Factors in determining the appropriate compensation for a role include experience, skills, knowledge, abilities, education, licensure and certification
About University of California San Diego
UC San Diego is an academic powerhouse and economic engine, recognized as one of the top 8 public universities by U.S. News and World Report. Innovation is central to who we are and what we do. Here, students learn that knowledge isn't just acquired in the classroom - life is their laboratory. UC San Diego's rich academic portfolio includes six undergraduate colleges, five academic divisions and five graduate and professional schools. The university's award-winning scholars are experts at the forefront of their fields with an impressive track record for achieving scientific, medical and technological breakthroughs.
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