Utilization Management Supervisor

University of California, San Francisco•San Francisco, CA

About The Position

The Utilization Management Supervisor reports to the Assistant Director of Utilization Management and serves as both a working supervisor and a clinical utilization management professional. Approximately 50% of the role involves direct utilization management activities, including medical necessity review and level-of-care determinations; the remaining 50% is focused 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 advance 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 UCSF Health Utilization Management Department is part of the multidisciplinary care team and is dedicated to advancing health through excellence, innovation, and patient-centered care. In alignment with UCSF Health’s mission and commitment to health equity, the department promotes timely access to appropriate services and resources across the continuum of care. Consistent with Joint Commission standards and regulatory requirements, it evaluates the medical necessity, appropriateness, level of care, and efficiency of services, treatments, procedures, and care settings to support safe, high-quality, cost-effective care, appropriate use of hospital resources, and continuity and coordination of care. The Supervisor provides operational and clinical oversight of case management staff, including training, mentorship, and workflow coordination. The role monitors caseloads for quality and consistency, facilitates resolution of complex and escalated cases, and leads process improvement efforts to enhance clinical outcomes, operational efficiency, and revenue integrity.

Requirements

Bachelor's degree in nursing, another healthcare profession, or a 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 effectively, 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 convey complex clinical and technical information, prepare reports, and present findings to interdisciplinary teams.
Advanced interpersonal skills to collaborate with physicians, leadership, staff, and external stakeholders, including payers and reviewers.
Ability to collaborate with Physician Advisors and facilitate escalation for 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 the ability to coordinate work, meet deadlines, and ensure 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 utilization management or case management information systems.
Ability to use data management systems to collect, analyze, and report utilization management data.
Demonstrated ability to maintain confidentiality, exercise discretion, and handle sensitive information appropriately.
Strong customer service orientation, with sensitivity to patient, provider, and payer needs and a focus on positive outcomes.
Strong problem-solving skills and a proactive, solution-oriented approach, with the ability to work effectively as part of a team.
Registered Nurse in the State of California.
InterQual Certified Instructor now or within six months of hire into the position.

Nice To Haves

Master’s degree in a healthcare-related field.
Accredited Case Manager (ACM) certification from the American Case Management Association.
Certified Case Manager (CCM) certification from the Commission for Case Manager Certification.
MCG Certified Expert or Instructor.
Knowledge of human resources policies and practices, including 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 as needed to address staffing gaps, ensure continuity of operations, and meet departmental productivity and quality expectations.
Supervises staff, including hiring, onboarding, performance evaluations, disciplinary actions, and staff development.
Ensures effective orientation, training, mentoring, and ongoing competency validation for team members; promotes professional development and access to continuing education and training.
Oversees and coordinates daily utilization management operations, including staff 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 and/or leads interdisciplinary utilization management activities to review cases, evaluate care options, and promote quality, efficiency, and appropriate resource utilization 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 enhance operational and financial outcomes.
Ensures adherence to applicable regulatory requirements, accreditation standards, and payer guidelines related to utilization management practices.
Communicates process, system, regulatory, and quality-standard updates to staff and interdisciplinary teams.
Oversees the accuracy of patient status determinations (inpatient versus observation) and ensures alignment with CMS guidelines and organizational policies.
Performs direct utilization management activities, including medical necessity review and level-of-care determinations.
Uses operational and performance metrics, including hospital capacity, length of stay, and denial trends, to monitor operations and identify opportunities for improvement.
Facilitates resolution of complex or escalated cases and supports consistent application of medical necessity criteria, payer guidelines, and regulatory standards.