Utilization Management Supervisor

The Utilization Management Supervisor reports to the Assistant Director of Utilization Management and serves in a dual capacity 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, with the remaining 50% focused on supervision, staff development, and operational oversight of the Utilization Management team.

In collaboration with clinical and administrative leadership, this position 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 Supervisor utilizes data and performance metrics—including hospital capacity, length of stay, and denial trends—to monitor operations, identify opportunities for improvement, and drive initiatives that enhance clinical, operational, and financial outcomes.

This role also ensures the consistent application of medical necessity criteria, regulatory requirements, and payer guidelines, while supporting compliance with accreditation standards and organizational goals.

Department Overview:

The UCSF Health Utilization Management Department is an integral component of the multidisciplinary care team, comprised of expert clinicians and staff 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, the Utilization Management Department evaluates the medical necessity, appropriateness, level of care, and efficiency of services, treatments, procedures, and care settings. These activities support safe, high-quality, and cost-effective care, ensure appropriate use of hospital resources, and promote continuity and coordination of care.

The Utilization Management Supervisor provides operational and clinical oversight of case management staff, including training, mentorship, and workflow coordination. This role ensures the accurate application of medical necessity criteria, payer guidelines, and regulatory standards, while supporting compliance with accreditation requirements. The Supervisor 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.

Required Qualifications: 

• Bachelor's degree in nursing( or other healthcare or related profession) OR 5 years of Case Management or Utilization Management equivalent leadership experience
• A minimum of two years recent Case Management, Utilization Management and/or Utilization Review work experience.
• Completed an InterQual or MCG training course
• Demonstrated ability to effectively supervise staff, manage complex workflows, and prioritize competing demands within utilization management and care coordination functions.
• 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 (e.g., InterQual and/or MCG)
• Knowledge of billing practices, documentation requirements, and regulatory/accreditation standards relevant to utilization management.
• Strong analytical and critical thinking skills, with 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 effective solutions, and recommend corrective actions based on data analysis and clinical review.
• Strong written and verbal communication skills, with the ability to clearly convey complex clinical and technical information, prepare reports, and present findings to interdisciplinary teams.
• Advanced interpersonal skills to collaborate effectively 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.
• Demonstrated ability to manage multiple  priorities, adapt to changing demands, and maintain productivity in a high-volume, fast-paced environment.
• Strong organizational skills with the ability to coordinate work, meet deadlines, and ensure accuracy and completeness of tasks.
• Self-directed with the ability to work independently in onsite or remote environments while maintaining expected productivity and accountability.
• Proficiency in standard business software (e.g., Microsoft Outlook, Word, 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 achieving positive outcomes.

• Strong problem-solving skills with a proactive, solution-oriented approach and ability to function effectively as part of a team.

   

Preferred Qualifications:

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

Licenses/Certifications:

• Registered Nurse in the State of California
• InterQual Certified Instructor now or within 6 months of hire into position