Utilization Management Lead — Clinical & Operations

UCSF Health, AG; San Francisco (CA); On-site; USD 120,000 - 160,000; Full time

Job summary

The UCSF Health Utilization Management Supervisor leads the clinical utilization management team while maintaining hands-on involvement in medical necessity reviews, level-of-care determinations, and policy compliance.

In collaboration with clinical and administrative leadership, you design and improve utilization management processes to promote efficient patient throughput, appropriate resource use, and high-quality care.

Qualifications

• Bachelor's degree in nursing or other healthcare or related profession OR 5 years of Case Management or Utilization Management equivalent leadership experience.
• Minimum of two years recent Case Management, Utilization Management and/or Utilization Review experience.
• InterQual or MCG training completed.
• Demonstrated ability to supervise staff, manage complex workflows, and prioritize demands within utilization management and care coordination.
• Strong knowledge of utilization management, case management, discharge planning, and managed care principles.
• Knowledge of billing practices, documentation requirements, and regulatory/accreditation standards relevant to utilization management.
• Strong analytical and communication skills; ability to interpret clinical information and exercise independent clinical judgment.
• Ability to lead process improvement and coordinate multiple priorities in a high-volume environment.

Responsibilities

• Provide operational and clinical oversight of case management staff, including training and workflow coordination.
• Monitor caseloads for quality and consistency and escalate complex cases.
• Apply medical necessity criteria, payer guidelines, and regulatory standards consistently.
• Lead process improvement initiatives to enhance clinical outcomes and revenue integrity.
• Collaborate with physicians, leadership, and external stakeholders to optimize utilization management.

Skills

Analytical thinking

Communication skills

Staff supervision

Data analysis

Project management

Clinical terminology

InterQual/MCG knowledge

Education

Bachelor's degree in nursing or related healthcare field

Master's degree in healthcare field (preferred)

Tools

InterQual training

Job description

The UCSF Health Utilization Management Supervisor leads the clinical utilization management team while maintaining hands-on involvement in medical necessity reviews, level-of-care determinations, and policy compliance.

In collaboration with clinical and administrative leadership, you design and improve utilization management processes to promote efficient patient throughput, appropriate resource use, and high-quality care.