Nurse Manager, Prior Authorization

SF Health Plan • San Francisco, CA

55d • $150,000 - $170,000 • Hybrid

About The Position

Reporting to the Director of Clinical Operations, the Nurse Manager, Prior Authorizations, provides clinical and operational leadership to the Prior Authorizations (PA) team within the Utilization Management (UM) function. You will manage a team of registered nurses and clinical staff responsible for prior authorization reviews, ensuring determinations are on time, clinically appropriate, and compliant with Medi-Cal, DHCS, and SFHP standards. Please note that while SFHP supports a hybrid work environment, you are required 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: $150,000 to $170,000 annual

Requirements

• Valid, unrestricted Registered Nurse (RN) or Nurse Practitioner (NP) license in the State of California.
• Bachelor's degree in Nursing or related field required.
• Minimum of 4+ years of clinical experience in a healthcare setting required; experience in managed care, case management, resource management, or utilization review, preferred.
• 2 to 4 years of supervisory or lead experience required.
• Experience with Medi-Cal, Medicare, DHCS, DMHC, and NCQA regulations preferred.

Responsibilities

• Manage a team of nurses and clinical staff responsible for prior authorization reviews, ensuring accurate application of UM criteria and timely completion of determinations.
• Define, communicate, and track individual and team goals aligned with departmental goals; ensure deliverables are met.
• Provide hands-on coaching and mentorship to staff.
• Monitor performance metrics, workload balance, and service quality; identify opportunities for development and process improvement.
• Conduct regular check-ins, providing meaningful feedback and recognition.
• Oversee daily operations of the PA team, including triage, documentation, and compliance with turnaround time standards.
• Ensure consistent application of evidence-based criteria (e.g., InterQual, MCG, SFHP policies, Medi-Cal and Medicare guidelines).
• Collaborate with UM leadership and Medical Directors to design and implement UM protocols, workflows, and staff training.
• Analyze authorization trends and performance data; develop action plans to address efficiency, accuracy, or quality gaps.
• Manage clinically related authorization and claims issues, escalating appropriately and ensuring timely resolution.

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: Manager
• Number of Employees: 251-500 employees