Utilization Management Outpatient Clinical Supervisor RN

KHS•Bakersfield, CA

18h•Onsite

About The Position

Under the direction of the Utilization Management Clinical Manager, the UM Outpatient Clinical Supervisor RN is responsible for supervising the functions and activities for all outpatient clinical level positions within the UM Department. The UM Outpatient Clinical Supervisor will work in a coordinated effort with the UM Clinical Manager to ensure smooth, efficient and productive operations within the UM Department, as directed by the Director of Utilization Management. The UM Outpatient Clinical Supervisor RN is responsible for supervising the Outpatient Clinical Intake Coordinator RN/LVN ensuring compliance with regulatory requirements, UM policies, and evidence‑based clinical guidelines. This position is accountable for the development and oversight of clinical training, competency validation, clinical auditing, quality monitoring, and performance improvement activities related to outpatient UM determinations and documentation. The Supervisor collaborates closely with the Outpatient NCIC Supervisor to ensure effective coordination between clinical and non-clinical workflows and to promote consistent, accurate, and timely authorization processing.

Requirements

Associate Degree in Nursing from an accredited institution or equivalent required
Possession of a valid California R.N. nursing license
5 years of full-time experience as a registered nurse in acute care and previous utilization/quality management experience in a managed care setting
2 years of supervisory or lead experience
Required travel up to 10%
Possession of valid California Driver’s License and proof of valid State required auto liability insurance

Nice To Haves

Bilingual (English/Spanish) preferred

Responsibilities

Supervise outpatient clinical staff, including Clinical Intake Coordinators (RN/LVN) and other licensed reviewers as applicable, to ensure compliance with UM policies, regulatory requirements, prior authorization turnaround time (TAT) standards, and evidence-based clinical criteria.
Oversee daily outpatient clinical workflow to ensure timely case assignment, review completion, and appropriate escalation.
Under the direction of the UM Outpatient Clinical Manager, train and support UM staff in the use of clinical platforms and core adjudication systems as they relate to utilization management processes and regulatory documentation requirements.
Works closely with Wellness and Prevention, Population Health Management Dept., Enhanced Care Management and CSS Teams to facilitate needs for members identified as High Risk or that require coordination of services.
Provide clinical support as needed in review of claim-related inquiries to validate alignment between authorized services and approved determinations.
Under the direction of the UM Outpatient Clinical Manager, oversee and maintain a structured outpatient clinical audit program to evaluate medical necessity determinations, documentation accuracy, regulatory compliance, and timeliness.
Trend findings, report results to leadership, and implement corrective action plans as indicated.
Assist UM Clinical Manager and Director of Utilization Management in the development and updating of UM criteria, guidelines, workflows, policies and procedures.
Provide guidance to clinical staff regarding Behavioral Health and other mental health conditions for coverage determination and coordination of services with appropriate internal departments and external partners as applicable.
Ensure appropriate coordination of medical services across departments and community resources to support timely authorization and access to care.
Monitor and address deficiencies in clinical decision-making or documentation identified through audit findings, compliance review, or performance monitoring activities.
Conduct performance evaluations of incorporating productivity, timeliness, documentation quality, audit findings, and adherence to regulatory standards.
Under the direction of the UM Clinical Director, oversee and manage the Interrater Reliability Review training for all outpatient clinical staff, including CMO and Medical Directors to facilitate consistent decisions based on evidence-based guidelines.
Provide input to the UM Outpatient Clinical Manager and the Director of Utilization Management regarding disciplinary issues.
Ensure proper coordination with KHS Medical Director(s), Pharmacy and other department as appropriate in making sound clinical decisions.
Remains current with California Children’s Services benefits and guidelines.
Monitors and reports production and quality of work by outpatient clinical staff.
Works with staff to achieve production, timeliness, accuracy, and quality of work.
Summarize and prepare necessary production reports for management.
Act as outpatient clinical liaison with Member Services, Claims, MIS, and Provider Network Management.
Works in a coordinated effort with the UM Outpatient Clinical Manager, Health Services Manager and Director of Utilization Management and Senior Director of Health Services Program Administrator to ensure the smooth and efficient operations of the outpatient processes.
Remain current with DHCS, DMHC, CMS, and NCQA regulatory requirements impacting prior authorization processes and ensure operational compliance.
Manage timecards, PTO, flex, and vacation schedules.
Adheres to all company policies and procedures related to employment and job responsibilities.
Performs other job-related duties as required.