Utilization Management Manager, Medicare Advantage - RN

University of California • Los Angeles, CA

393d • $112,900 - $256,900

About The Position

The Manager for Medicare Advantage Utilization Management at UCLA Health plays a crucial role in overseeing a team of UM coordinators and nurses, ensuring the delivery of exceptional patient care. This position involves collaborating with Medicare Advantage leadership to manage various initiatives related to utilization management (UM) administrative, operational, and strategic objectives. The role emphasizes leadership, effective communication, and fostering collaborative relationships within the organization.

Requirements

• Current unrestricted RN licensure in CA required.
• Bachelor's of Science in Nursing (BSN) degree required.
• Five or more years of utilization management experience required.
• Four or more years of managerial experience required.
• Four or more years of clinical experience providing direct patient care in an HMO environment required.
• Thorough knowledge of the health care industry, utilization review, and concurrent review required.
• Knowledge of Health Plan, DMHC, CMS, HIPAA, and NCQA requirements.
• Familiarity with CPT-4, ICD-10, and HCPCS codes required.
• Proficient computer skills including Microsoft Word, Excel, and Managed Care software (e.g., EZ Cap, Diamond, IDX) required.
• Strong critical thinking, problem solving, and analytical skills required.
• Excellent communication, organizational, and prioritizing skills required.

Nice To Haves

• ACM - Accredited Case Manager preferred.
• CCM - Certified Case Manager preferred.

Responsibilities

• Provide direct management to a team of UM coordinators and nurses.
• Work closely with Medicare Advantage leadership to plan, execute, and manage UM initiatives.
• Oversee and coordinate pre-service authorizations and denial letters.
• Manage concurrent reviews and continuity of care processes.
• Handle retro claims and retrospective reviews.
• Implement referral automation and business rules/configuration.

Benefits

• Competitive salary range of $112,900 - $256,900 annually.
• Opportunities for professional development and career advancement.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Industry: Educational Services
• Education Level: Bachelor's degree
• Number of Employees: 101-250 employees