Director, Clinical Operations (Utilization Management)

SF Health Plan • San Francisco, CA

5d • $195,000 - $215,000 • Hybrid

About The Position

Reporting to the Senior Director, Health Services Clinical Operations, the Director, Clinical Operations provides strategic and operational leadership. This leadership is for SFHP's Utilization Management (UM) program, ensuring members receive medically necessary, and cost-effective care. You will oversee all UM activities. These activities include prior authorization, concurrent review, discharge planning, and delegated oversight. Additionally, you will ensure compliance with CMS, DHCS, DMHC, and NCQA standards. You will manage a matrixed clinical and administrative team. You will work with the Medical Directors. The Director partners across Health Services, Quality, Compliance, Claims, Provider Network Operations, and other internal and external teams. The goal of this partnership is to improve utilization review processes, improve efficiency, and support affordability goals. You will be SFHP's primary leader for UM performance, policy implementation, and regulatory readiness. Please note that while SFHP supports a hybrid work environment, SFHP requires you to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office. Salary: $195,000 - $215,000 per year

Requirements

• Current, unrestricted California Registered Nurse (RN) license.
• Bachelor's degree in Nursing or a related health field required; Master's degree in Nursing, Health Administration, or related discipline,
• Minimum of 7 years of progressively responsible management experience in Utilization Management or related managed care operations, including leadership of managers or multi-level teams.
• Experience designing and implementing strategic programs that improve efficiency, compliance, and quality.
• Knowledge of California and federal insurance programs, Medi-Cal/Medicaid experience,
• Experience leading teams and representing operational areas in enterprise-level strategy forums.

Responsibilities

• Lead daily operations of the Utilization Management department, including prior authorization, concurrent review, and discharge planning functions.
• Manage departmental structure, staffing, and workflows to ensure determinations and high-quality service delivery.
• Manage and develop the UM leadership team, ensuring clarity of roles, accountability, and professional growth.
• Establish department performance goals, dashboards, and quality metrics; monitor results and take corrective action.
• Maintain departmental policies and procedures consistent with DHCS, DMHC, and NCQA requirements.
• Ensure the UM program operates in full compliance with applicable regulations and accreditation standards.
• Oversee UM delegation oversight activities, including annual medical group audits, review of corrective action plans (CAPs), and preparation of audit documentation.
• Collaborate with Compliance and Quality teams to maintain readiness for internal and external reviews.
• Partner with the Medical Directors to ensure clinical consistency in decision-making and adherence to SFHP policies.
• Analyze utilization trends and performance data to identify opportunities for cost reduction and improved member outcomes.
• Lead process redesign and workflow optimization efforts to improve efficiency and reduce administrative burden.
• Partner with Claims, Performance Process Improvement, and IT to enhance automation, data accuracy, and integration between authorization and claims systems.
• Support programs to align UM practices with Care Management and Population Health programs, ensuring seamless transitions of care.
• Develop, implement, and monitor corrective and preventive action plans to address operational gaps our audit findings.
• Be an operational liaison between SFHP and contracted hospitals, IPAs, and providers regarding UM policies and authorization processes.
• Participate in internal and external committees, including the Utilization Management Committee and Clinical Oversight Committee.
• Provide subject matter expertise for organizational projects involving utilization policy, benefits implementation, or network performance.
• Communicate with senior leadership and cross-department partners on UM outcomes, challenges, and strategic priorities.
• Develop and manage the UM department budget, monitoring expenditures and aligning resource use with program goals.
• Use data analytics and financial reports to assess utilization patterns and support affordability programs.
• Collaborate with Finance and Analytics teams to prepare forecasts, reports, and regulatory submissions related to UM activity.
• Promote a culture of collaboration, accountability, and learning; provide mentorship, coaching, and professional development for UM managers and staff.
• Ensure onboarding, training, and continuing education for all employees, and partner with HR to recruit, retain, and develop top talent.

Benefits

• Health Benefits Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
• Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
• Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
• Retirement Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
• Time off 23 days of Paid Time Off (PTO) and 13 paid holidays.
• Professional development: Opportunities for tuition reimbursement, professional license/membership.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Number of Employees: 251-500 employees