(RN) Prior Authorization UM Case Manager - Hybrid - 134812

University of California - San Diego Medical Centers
United States, California, San Diego
Mar 14, 2025
UCSD Layoff from Career Appointment: Apply by 03/18/2025 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor. Special Selection Applicants: Apply by 03/27/25. Eligible Special Selection clients should contact their Disability Counselor for assistance. This position may work a hybrid schedule which includes a combination of working both onsite at Greenwich Drive and remote. Current department requirement is on-site one day per week. DESCRIPTION UC San Diego Health is a Magnet designated organization, which is a prestigious recognition that applies to only 10% of all U.S. hospitals. Magnet is the "gold standard" for nursing excellence and is based on strengths in five key areas, which include transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovation and improvements and empirical outcomes. UC San Diego Health has held its Magnet status since 2011. The Prior Authorization UM Case Manager is responsible for managing the prior authorization process for various medical services, procedures, and medications. This includes ensuring that requests meet established criteria and are processed efficiently while adhering to insurance policies and medical necessity guidelines. Additionally, this role involves coordinating with healthcare providers, insurance companies, and internal teams to facilitate appropriate care and manage authorization requests effectively. While not required, a cover letter is highly recommended when applying to this position. MINIMUM QUALIFICATIONS Must be a graduate from an accredited school of Nursing. RN license issued by the State of California. Minimum two (2) years of RN experience in prior authorization, utilization management, or a related healthcare field. Proven background in managing prior authorization processes. Strong preference for experience in handling outpatient services and working with insurance companies. Well-versed in medical terminology and evidence-based guidelines such as Health Plan policies and MCG (Milliman Care Guidelines) to assess the necessity and appropriateness of requested services. Proficiency in Information Systems and computer programs such as Word and Excel. Must possess excellent interpersonal and communication skills. Must be able to work within a team environment. PREFERRED QUALIFICATIONS BSN or Master's Degree. ACM and/or CCM certificate. Epic knowledge and experience. SPECIAL CONDITIONS Must have access to high-speed internet when working remotely. Must be able to work various hours and locations based on business needs. Employment is subject to a criminal background check and pre-employment physical. Pay Transparency Act Annual Full Pay Range: $144,711 - $190,885 (will be prorated if the appointment percentage is less than 100%) Hourly Equivalent: $69.31 - $91.42 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).