Utilization Manager Jobs in Oceanside, CA (NOW HIRING)

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.

• 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.

• 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.

• Previous UM experience working for an IPAN/ 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.

• Employment is subject to a criminal background check and a 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. Additional onsite days may be required based on department and business needs.

As a condition of employment, the final candidate who accepts an offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; or have filed an appeal of a finding of substantiated misconduct with a previous employer.

• UC Sexual Violence and Sexual Harassment Policy
• UC Anti-Discrimination Policy
• Abusive Conduct in the Workplace

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).

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.