PACE Manager, Utilization and Referral Services

Family Health Centers of San Diego•San Diego, CA

About The Position

The Manager, Utilization and Referral Services is responsible for leading and overseeing all referral and scheduling operations for the PACE (Program of All-Inclusive Care for the Elderly) program. This role ensures timely access to care, efficient coordination of services, and strict compliance with federal PACE regulations (42 CFR Part 460) and California Department of Health Care Services (DHCS) requirements. The Manager, Utilization and Referral Services provides guidance to referral and scheduling staff and partners closely with PACE Assistant Medical Director, with the Interdisciplinary Team (IDT) attending daily IDT meetings, with the Compliance Manager, with leadership in Clinical Operations, , Transportation, and IT, and plays a critical role in ensuring participant-centered, compliant, and efficient service delivery across the continuum of care.

Requirements

Bachelor’s degree in healthcare administration, public health, business administration, or a related field (Master’s degree preferred).
Traveling between sites and other locations is required as an essential function of the job. Must have a car, a valid California driver’s license, and proof of minimum levels of car insurance as required under California law, although limits of $100,000 are recommended. An acceptable driving record is also required. California law requires all drivers to obtain a valid California driver’s license within ten days of establishing residency. Mileage and other reimbursement governed by policy.
Minimum of 3–5 years of healthcare operations or management experience required, preferably in PACE, managed care, Medicaid, or geriatric services.
Demonstrated knowledge of PACE regulations, CMS requirements, and California Medi-Cal/DHCS guidelines.
Experience managing referrals, intake, scheduling, or access-to-care operations.
Proven leadership and staff management experience.
Experience working directly in a PACE program or with frail elderly populations.
Familiarity with interdisciplinary team models of care.
Experience with EHR and scheduling systems used in managed care or PACE environments.
Strong organizational and analytical skills
Excellent communication and interpersonal abilities
Ability to interpret and apply complex regulations.
Process improvement and critical thinking skills.
Commitment to participant-centered, culturally competent care

Responsibilities

Regulatory Compliance Ensure departmental operations comply with CMS PACE regulations (42 CFR Part 460), including requirements related to assessments, care planning, timeliness, and interdisciplinary team coordination.
Works in close collaboration with PACE Assistant Medical Director to monitor utilization patterns in line with quality indicators to optimize referral authorizations.
Works with referrals and scheduling staff providing guidance as it applies to referrals, scheduling, and access to care.
Support compliance with PACE requirements for timeliness of referrals authorizations and scheduling of specialty appointments.
Maintain accurate documentation and reporting required for CMS and DHCS audits, surveys, and monitoring activities.
Partner with the Compliance Manager to identify, investigate, and resolve potential compliance risks related to referral and scheduling workflows.
Works in close collaboration with QA Coordinator to monitor service delivery requests and grievances related to denials.
Referral & Intake Management Supervise referral and scheduling staff responsible for receiving referrals, reviewing, authorizing, and scheduling appointments.
Establish and monitor referral performance standards, including time to first contact and time to schedule specialists’ appointments.
Maintain strong relationships with the various interdisciplinary team and primary care providers, as well as external clinical providers such as hospitals and specialists.
Scheduling & Access Operations Lead all specialty care scheduling operations and transportation.
Develop and maintain scheduling templates, rules, and workflows that support timely access to care and compliance with PACE requirements.
Supervise scheduling staff and ensure effective coordination among clinical providers, transportation services, and external partners.
Monitor appointment availability, utilization, cancellations, and no-show trends; implement corrective strategies as needed.
Coordinate daily or routine scheduling huddles to address urgent needs, provider availability changes, and participant issues.
Ensure accurate and timely data entry in CMIS and PACE dashboard.
Develop and analyze reports related to referral volume, scheduling performance, and access metrics.
Track and report key indicators such as wait times and appointment adherence.
Identify trends, gaps, and operational risks; lead or participate in quality improvement initiatives.
Address escalated participant, caregiver, and referral partners concerns related to access, scheduling, or authorizations.
Ensure clear communication with participants and caregivers regarding appointment schedules and processes.
Support outreach and education efforts related to referral processes and PACE services.