oracle
Utilization Management Supervisor
University of California, San Francisco
San Francisco, USA
Mid · 5+ years experience
Onsite
Discovered Yesterday
Role Overview
The UCSF Health Utilization Management Department is an integral component of the multidisciplinary care team, comprised of expert clinicians and staff dedicated to advancing health through excellence, innovation, and patient-centered care.
In alignment with UCSF Health’s mission and commitment to health equity, the department promotes timely access to appropriate services and resources across the continuum of care.
Consistent with Joint Commission standards and regulatory requirements, the Utilization Management Department evaluates the medical necessity, appropriateness, level of care, and efficiency of services, treatments, procedures, and care settings.
These activities support safe, high-quality, and cost-effective care, ensure appropriate use of hospital resources, and promote continuity and coordination of care.
The Utilization Management Supervisor provides operational and clinical oversight of case management staff, including training, mentorship, and workflow coordination.
This role ensures the accurate application of medical necessity criteria, payer guidelines, and regulatory standards, while supporting compliance with accreditation requirements.
The Supervisor monitors caseloads for quality and consistency, facilitates resolution of complex and escalated cases, and leads process improvement efforts to enhance clinical outcomes, operational efficiency, and revenue integrity.
Full Job Posting
Required Qualifications:
- Bachelor's degree in nursing( or other healthcare or related profession) OR 5 years of Case Management or Utilization Management equivalent leadership experience
- A minimum of two years recent Case Management, Utilization Management and/or Utilization Review work experience.
- Completed an InterQual or MCG training course
- Demonstrated ability to effectively supervise staff, manage complex workflows, and prioritize competing demands within utilization management and care coordination functions.
- Strong knowledge of utilization management, case management, discharge planning, and managed care principles.
- Working knowledge of medical terminology, anatomy and physiology, disease processes, surgical procedures, and medical record documentation and coding standards.
- Knowledge and experience applying medical necessity criteria (e.g., InterQual and/or MCG)
- Knowledge of billing practices, documentation requirements, and regulatory/accreditation standards relevant to utilization management.
- Strong analytical and critical thinking skills, with the ability to interpret clinical information, apply medical necessity criteria, and exercise independent clinical judgment when guidelines are not explicit.
- Ability to identify problems, evaluate alternatives, implement effective solutions, and recommend corrective actions based on data analysis and clinical review.
- Strong written and verbal communication skills, with the ability to clearly convey complex clinical and technical information, prepare reports, and present findings to interdisciplinary teams.
- Advanced interpersonal skills to collaborate effectively with physicians, leadership, staff, and external stakeholders, including payers and reviewers. Ability to collaborate with Physician Advisors and facilitate escalation for complex medical necessity or level-of-care determinations.
- Ability to educate and mentor staff and provide in-service training to clinical teams.
- Demonstrated ability to manage multiple priorities, adapt to changing demands, and maintain productivity in a high-volume, fast-paced environment.
- Strong organizational skills with the ability to coordinate work, meet deadlines, and ensure accuracy and completeness of tasks.
- Self-directed with the ability to work independently in onsite or remote environments while maintaining expected productivity and accountability.
- Proficiency in standard business software (e.g., Microsoft Outlook, Word, Excel) and utilization management or case management information systems.
- Ability to use data management systems to collect, analyze, and report utilization management data.
- Demonstrated ability to maintain confidentiality, exercise discretion, and handle sensitive information appropriately. Strong customer service orientation with sensitivity to patient, provider, and payer needs and a focus on achieving positive outcomes.
- Strong problem-solving skills with a proactive, solution-oriented approach and ability to function effectively as part of a team.
Preferred Qualifications:
- Master’s degree in a healthcare related field
- Accredited Case Manager (ACM) American Case Management Association or Certified Case Manager (CCM) Commission for Case Manager Certification
- MCG Certified Expert or Instructor
- Knowledge of human resources policies and practices, with the ability to train, mentor, evaluate performance, and participate in employment-related decision-making.
- Licenses/Certifications:
- Registered Nurse in the State of California
- InterQual Certified Instructor now or within 6 months of hire into position
- Responsibilities
- % of timeEssential Function (Yes/No)Key Responsibilities (To be completed by Supervisor)
- 50
- Yes
- Working Supervisor / Staffing Support
- Maintains comprehensive working knowledge of all staff roles and functions; provides direct operational support by performing these duties as needed to address staffing gaps, ensure continuity of operations, and meet departmental productivity and quality expectations.
- 20
- Leadership & Human Resources Management
- Supervises staff, including hiring, onboarding, performance evaluations, disciplinary actions, and staff development.
- Ensures effective orientation, training, mentoring, and ongoing competency validation for team members.
- Promotes professional development and facilitates access to continuing education and training opportunities.
- 10
- Operational Oversight
- Oversees and coordinates daily utilization management operations, including staff scheduling, workload distribution, and resolution of operational or system issues to ensure efficient and continuous workflow.
- Serves as a clinical and operational resource, advising on work methods and supporting complex cases and escalated issues.
- Implements and evaluates new methods, systems, and processes to improve utilization management performance and efficiency.
- Care Coordination & Interdisciplinary Leadership
- Coordinates and/or leads interdisciplinary utilization management activities involving clinical and non-clinical staff to review cases, evaluate care options, and promote quality, efficiency, and appropriate resource utilization across the continuum of care.
- 5
- Data, Reporting & Performance Improvement
- Collects, analyzes, and reports data related to utilization management activities, including quality outcomes, cost and utilization trends, resource management, and regulatory compliance.
- Identifies performance improvement opportunities and collaborates with leadership to develop and implement action plans that enhance operational and financial outcomes.
- Regulatory Compliance & Communication
- Ensures adherence to applicable regulatory requirements, accreditation standards, and payer guidelines related to utilization management practices.
- Communicates updates regarding processes, systems, regulatory changes, and quality standards to staff and interdisciplinary teams to ensure alignment and compliance.
- Oversees accuracy of patient status determinations (inpatient vs. observation) and ensures alignment with CMS guidelines and organizational policies.
Responsibilities
- % of timeEssential Function (Yes/No)Key Responsibilities (To be completed by Supervisor)
- 50
- Yes
- Working Supervisor / Staffing Support
- Maintains comprehensive working knowledge of all staff roles and functions; provides direct operational support by performing these duties as needed to address staffing gaps, ensure continuity of operations, and meet departmental productivity and quality expectations.
- 20
- Leadership & Human Resources Management
- Supervises staff, including hiring, onboarding, performance evaluations, disciplinary actions, and staff development.
- Ensures effective orientation, training, mentoring, and ongoing competency validation for team members.
- Promotes professional development and facilitates access to continuing education and training opportunities.
- 10
- Operational Oversight
- Oversees and coordinates daily utilization management operations, including staff scheduling, workload distribution, and resolution of operational or system issues to ensure efficient and continuous workflow.
- Serves as a clinical and operational resource, advising on work methods and supporting complex cases and escalated issues.
- Implements and evaluates new methods, systems, and processes to improve utilization management performance and efficiency.
- Care Coordination & Interdisciplinary Leadership
- Coordinates and/or leads interdisciplinary utilization management activities involving clinical and non-clinical staff to review cases, evaluate care options, and promote quality, efficiency, and appropriate resource utilization across the continuum of care.
- 5
- Data, Reporting & Performance Improvement
- Collects, analyzes, and reports data related to utilization management activities, including quality outcomes, cost and utilization trends, resource management, and regulatory compliance.
- Identifies performance improvement opportunities and collaborates with leadership to develop and implement action plans that enhance operational and financial outcomes.
- Regulatory Compliance & Communication
- Ensures adherence to applicable regulatory requirements, accreditation standards, and payer guidelines related to utilization management practices.
- Communicates updates regarding processes, systems, regulatory changes, and quality standards to staff and interdisciplinary teams to ensure alignment and compliance.
- Oversees accuracy of patient status determinations (inpatient vs. observation) and ensures alignment with CMS guidelines and organizational policies.
About University of California, San Francisco
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