Job Description
The UM Nurse Manager is responsible for providing strategic and operational leadership to the day to day function of the Utilization Management Team. The UM Nurse Manager will ensure that the team complies with timeliness, documentation, notification and review quality standards based on the Federal, State, Health Plan and Accreditation requirements. Main responsibilities include but not limited to assigning shift schedule, delegating reviews, providing direction on review priorities, meeting the demands of internal and external partners, and ensuring that the team is meeting departmental and regulatory metrics. Ensures that staff achieves performance goals while adhering to applicable internal and external policies, procedures, rules and guidelines Participates in the recruitment, selection, and on-boarding of newly hired staff assigned to the UM team.
Responsibilities
Essential Functions:
• Ensures that the team are properly trained to conduct medical necessity reviews on incoming Pre-Service/Prior-Authorization, Retrospective and Post Claims reviews on Urgent/Expedited and Routine/Standard referrals/authorizations requests in compliance with any Federal, State, Health Plan, Accreditation (URAC, NCQA) requirements.
• Assures staff accountability through routine evaluation, reporting and performance observation, and through timely, thorough preparation of annual review. Ensures that staff achieves performance goals while adhering to applicable internal and external policies, procedures, rules and guidelines
• Ensures that the UM team documents on the Medical Management System in a timely manner, all supporting clinical information, outreach attempts (if applicable) and criteria used to make a determination.
• Adheres to compliance with all federal, state, health plan and accreditation by all laws, standards and regulations.
• Collaborate with hospital/facility staff, providers, coordinators, Medical Director, members and their care givers to provide the level of care necessary to meet member's health needs.
• Maintain an active role in ensuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planners/ case managers or other staff in the early identification discharge needs/disposition and determining appropriate level of care placement.
• Monitor, track, and report any trending inappropriate referrals/authorization to the UM Medical Director and/or the Director of Medical Management.
• Ensure network provider steerage and happening on OON network request and negotiate with Clinic Operations as appropriate.
• Identify and manage high risk members for readmission or with complex medical and psychosocial needs. Collaborate with Case Management Team to coordinate post discharge care and services to ensure timely outpatient follow-up, and the provider treatment plan, medications & outpatient services are in place prior to discharge.
• Serves as a subject matter expert on appropriate use, interpretation and documentation of clinical criteria in the review process such as National Coverage Determination (NCD), Local Coverage Articles (LCA), Local Coverage Determination (LCD), California Coverage Determinations, Health Plan Medical Coverage Policies, MCG, NCCN etc.
• Contribute to program goals and objectives in containing health care costs and maintaining a high-quality medical delivery system through the program procedures for conducting UM activities.
• Demonstrate proficiency with the principles and methodologies of process improvement. Strategically apply these in the execution of responsibilities in support of a process focused approach
• Participate on UM Committee meetings and annual health plan audit.
• Other duties as assigned.
Qualifications
Required
• Registered Nurse (RN) in the State of California
• At least 3 to 5 years of Nursing Management Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
• At least 5-10 years of Nursing Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
• Computer experience in MS Word, Excel and MS Office Programs
• Experience with Medicare/Medicare Advantage Plans, Commercial Plans, HMO, and/or Medi-Cal/ACA standards
Preferred
• 2 to 3 years of UM Manager Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
• Bachelor's degree in a health care related field
Skills or Other Qualifications
Required:
• Proven and effective problem-solving, critical thinking, and decision-making skills.
• Collaborative, team-oriented approach to decision-making.
License and Certification
Required: Registered Nurse
Preferred: N/A
About Us
Hoag Memorial Hospital Presbyterian is a nonprofit regional health care delivery network in Orange County, California, consisting of three acute-care hospitals with sixteen urgent care centers, eleven health centers and a network of more than1,800 physicians, 100 allied health members, 8,000 employees, and 2,000 volunteers. More than 30,000 inpatients and 550,000 outpatients choose Hoag each year.
For over 70 years, Hoag has delivered a level of personalized care that is unsurpassed among Orange County's health care providers. Since 1952, Hoag has served the local communities and continues its mission to provide the highest quality health care services through the core strategies of quality and service, people, physician partnerships, strategic growth, financial stewardship, community benefit and philanthropy.
Hoag offers a comprehensive blend of health care services including six institutes providing specialized care in the areas of cancer, heart and vascular, neurosciences, women's health, orthopedics, and digestive health through our institutes.
Hoag was the highest ranked hospital in Orange County in the 2024-2025 U.S. News &World Report, the only Orange County hospital ranked in the top 10 for California. The organization was ranked the #5 hospital in the Los Angeles Metro Area and the #10 hospital in California.
To learn more about Hoag's awards and accreditations, visit: https://www.hoag.org/about-hoag/awards-accreditations/.
Hoag is an Equal Opportunity Employer and prohibits discrimination and harassment of any kind. Hoag is committed to the principle of equal employment opportunity for all employees and providing employees with a work environment free of discrimination and harassment. Hoag hires a diverse group of people in a manner that allows them to reach their full potential in the pursuit of organizational objectives.
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