Utilization Management Supervisor

UCSF•San Francisco, CA

10d•$139,000 - $326,000

About The Position

The Utilization Management Supervisor reports to the Assistant Director of Utilization Management and serves as both a working supervisor and clinical utilization management professional. Approximately 50% of the role is dedicated to direct utilization management activities, including medical necessity review and level-of-care determinations; the remaining 50% focuses on supervision, staff development, and operational oversight of the Utilization Management team. In collaboration with clinical and administrative leadership, the Supervisor supports the design, implementation, and continuous improvement of utilization management processes that promote efficient patient throughput, appropriate resource utilization, and high-quality patient care. The role uses data and performance metrics—including hospital capacity, length of stay, and denial trends—to monitor operations, identify improvement opportunities, and lead initiatives that enhance clinical, operational, and financial outcomes. The Supervisor ensures consistent application of medical necessity criteria, regulatory requirements, and payer guidelines, and supports compliance with accreditation standards and organizational goals. The position provides operational and clinical oversight of case management staff, including training, mentorship, workflow coordination, caseload quality and consistency, and resolution of complex or escalated cases. The Supervisor also leads process improvement efforts to enhance clinical outcomes, operational efficiency, and revenue integrity.

Requirements

Bachelor's degree in nursing, another healthcare or related profession, or five years of equivalent Case Management or Utilization Management leadership experience.
At least two years of recent Case Management, Utilization Management, and/or Utilization Review work experience.
Completion of an InterQual or MCG training course.
Demonstrated ability to supervise staff, manage complex workflows, and prioritize competing demands in utilization management and care coordination.
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 such as InterQual and/or MCG.
Knowledge of billing practices, documentation requirements, and regulatory and accreditation standards relevant to utilization management.
Strong analytical and critical-thinking skills, including 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 solutions, and recommend corrective actions based on data analysis and clinical review.
Strong written and verbal communication skills, including the ability to explain complex clinical and technical information, prepare reports, and present findings to interdisciplinary teams.
Advanced interpersonal skills and ability to collaborate with physicians, leadership, staff, external stakeholders, payers, and reviewers.
Ability to collaborate with Physician Advisors and facilitate escalation of complex medical necessity or level-of-care determinations.
Ability to educate and mentor staff and provide in-service training to clinical teams.
Ability to manage multiple priorities, adapt to changing demands, and maintain productivity in a high-volume, fast-paced environment.
Strong organizational skills, including coordinating work, meeting deadlines, and ensuring accuracy and completeness.
Self-directed ability to work independently in onsite or remote environments while maintaining expected productivity and accountability.
Proficiency in standard business software such as Microsoft Outlook, Word, and Excel, and in utilization management or case management information systems.
Ability to use data management systems to collect, analyze, and report utilization management data.
Ability to maintain confidentiality, exercise discretion, and appropriately handle sensitive information.
Strong customer service orientation and sensitivity to patient, provider, and payer needs, with a focus on positive outcomes.
Strong problem-solving skills and a proactive, solution-oriented approach, with the ability to function effectively as part of a team.
Registered Nurse license in the State of California.
InterQual Certified Instructor certification, either at hire or within six months of hire.

Nice To Haves

Master’s degree in a healthcare-related field.
Accredited Case Manager (ACM) certification from the American Case Management Association or Certified Case Manager (CCM) certification from the 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.

Responsibilities

Maintains working knowledge of staff roles and functions and provides direct operational support to address staffing gaps, maintain continuity, and meet productivity and quality expectations.
Supervises staff, including hiring, onboarding, performance evaluations, disciplinary actions, and staff development.
Provides orientation, training, mentoring, and ongoing competency validation, and facilitates professional development and continuing education opportunities.
Oversees and coordinates daily utilization management operations, including scheduling, workload distribution, and resolution of operational or system issues.
Serves as a clinical and operational resource, advising on work methods and supporting complex cases and escalated issues.
Implements and evaluates methods, systems, and processes to improve utilization management performance and efficiency.
Coordinates or leads interdisciplinary utilization management activities to review cases, evaluate care options, and promote quality, efficiency, and appropriate resource use across the continuum of care.
Collects, analyzes, and reports data on 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 improve operational and financial outcomes.
Ensures adherence to regulatory requirements, accreditation standards, and payer guidelines relevant to utilization management.
Communicates process, system, regulatory, and quality updates to staff and interdisciplinary teams.
Oversees the accuracy of inpatient-versus-observation status determinations and alignment with CMS guidelines and organizational policies.
Supports medical necessity review and level-of-care determinations, and ensures consistent use of medical necessity criteria and payer guidelines.
Monitors caseloads for quality and consistency and facilitates resolution of complex and escalated cases.