RN, Pre-Services UM Supervisor (Remote) CA License

Supervisor, Pre-Service (Utilization Management)

The Supervisor of Utilization Management Pre-Service (Clinical) leads a clinical pre-service team focused on prior authorization and pre-service utilization review. This role oversees day-to-day operations, directs a team of nurses and coordinators, and ensures that pre-service utilization management activities meet regulatory, timeliness, and quality standards. The supervisor maintains expert knowledge of commercial and government payer requirements, NCQA standards, and clinical criteria, while driving process improvement initiatives and collaborating with internal departments and external providers to support patient-centered, compliant utilization management.

Responsibilities

• Oversee day-to-day pre-service utilization management operations, ensuring work queues move efficiently and cases are processed in a timely manner.
• Supervise and coach a team of approximately 20 nurses and clinical staff, monitoring productivity, identifying challenges, and providing guidance and support.
• Provide direct leadership oversight for assigned clinical pre-service teams, including staff assignments and daily direction.
• Supervise Utilization Management Nurses and Coordinators, including conducting timely performance evaluations, addressing performance issues, and identifying training needs.
• Escalate operational and clinical issues appropriately and provide clear direction to staff on resolution and next steps.
• Assist with processing remaining authorizations and pre-service reviews when needed to support team productivity and timeliness.
• Maintain current and accurate knowledge of commercial and government payer requirements, CMS, DMHC, NCQA, DHCS regulations, and health plan guidelines related to utilization management.
• Partner with the non-clinical pre-service team as needed to align and improve current workflows and processes.
• Support the UM Pre-Service Director and Delegation Oversight team in developing and updating departmental manuals, procedures, and processing standards related to the authorization process.
• Maintain authorization production standards and statistics, ensuring production meets timeliness goals established by regulatory agencies and health plans, and report performance to management on a daily basis.
• Develop, implement, and monitor standardized protocols for clinical team activities to facilitate integrated, proactive case management.
• Act as a liaison with external organizations, maintaining effective lines of communication and collaborating directly with physicians and community providers as needed.
• Evaluate staff performance and determine the quality of their work efforts, ensuring adherence to clinical and operational standards.
• Develop or assist in the development of prior authorization and claims policies, incorporating current literature and professionally recognized standards.
• Develop or assist in the development and implementation of policies and plans for effective patient-centered utilization management with a focus on pre-service activities.
• Design and implement ongoing programs to measure, assess, and improve the quality of processes, workflows, treatment, and services delivered to patients.
• Ensure optimal quality of care and service is provided through robust utilization management practices and continuous quality improvement.
• Participate in Quality Assurance Programs, intervene in crisis situations, and investigate unusual incidents related to utilization management operations.
• Lead and participate in departmental and cross-functional meetings, and represent the department in discussions and initiatives as needed.
• Provide management-level oversight, including staff leadership, program management, and effective issue resolution within the pre-service utilization management function.
• Apply nursing processes, case management principles, and continuity of care concepts to utilization review decisions across the age continuum.
• Apply appropriate business rules, medical guidelines, clinical criteria, and health plan benefits to authorization decision-making, documenting rationale and research clearly.
• Collaborate with stakeholders to navigate network and benefit limitations, identify alternatives that meet patient needs, and support positive clinical and financial outcomes.
• Utilize disease management strategies and clinical criteria tools to support accurate level-of-care determinations and appropriate utilization of services.

Essential Skills

• Active Registered Nurse (RN) license required.
• Must hold a California RN license, including when working remotely from another state.
• Extensive expertise in pre-service utilization management, including pre-certification, prior authorizations, turnaround times, requirements, criteria hierarchy, and appeals.
• Minimum of 3 years of recent clinical nursing experience.
• Experience supervising staff and monitoring productivity and performance in a clinical or utilization management setting.
• Strong experience in pre-service reviews and UM compliance, including application of criteria hierarchy and adherence to turnaround time cutoffs.
• Proficiency in utilization review and concurrent review processes.
• Experience with prior authorization operations in managed care or IPA environments.
• Knowledge and application of Milliman Care Guidelines (MCG) and other clinical criteria tools.
• Knowledge of InterQual criteria and NCQA standards related to utilization management.
• Ability to apply clinical criteria to determine appropriate level of care for admissions and services, with clear documentation of rationale and research.
• Knowledge of nursing processes, case management, and continuity of care across the age continuum and life span.
• Ability to apply business rules, medical guidelines, and health plan benefits to authorization decisions.
• Understanding of network structures, benefit limitations, and strategies to identify alternatives that support patient needs.
• Knowledge of disease management strategies and their integration into utilization management.
• Demonstrated management-level capabilities, including staff oversight, program management, and issue resolution.
• Strong communication skills for working directly with physicians, community providers, and internal stakeholders.
• Ability to develop, implement, and monitor protocols, policies, and quality improvement programs within utilization management.

Additional Skills & Qualifications

• Minimum of 3 years of experience in an IPA or managed care setting preferred.
• MSO (Management Services Organization) Experience preferred, including experience with multiple health plan contracts and Medicare.
• Experience with MCG criteria application preferred.
• Experience with EZ authorization or similar utilization management systems is a plus.
• Leadership or supervisory experience in a lead role, with readiness to transition into a formal supervisory position, is welcome when supported by strong pre-service expertise.
• Experience participating in Quality Assurance Programs and process improvement initiatives.
• Ability to develop and update departmental manuals, procedures, and processing standards related to authorization workflows.
• Experience working within NCQA-regulated environments and meeting CMS, DMHC, DHCS, and health plan timeliness standards.
• Familiarity with care management tools, referral coordination, and care roadmap frameworks.
• Comfort working with large, complex health systems and multiple payer requirements.

Work Environment

This position operates in a remote work environment with a structured schedule from Monday through Friday, 8:00 AM to 5:00 PM Pacific Standard Time. Team members work California hours regardless of their physical location. The role involves regular use of clinical criteria tools such as Milliman Care Guidelines (MCG) and InterQual, as well as utilization management and prior authorization systems, including EZ authorization or similar platforms. Work is highly collaborative, requiring frequent interaction with nurses, coordinators, physicians, community providers, and cross-functional departments. The environment emphasizes data-driven performance monitoring, adherence to regulatory and health plan standards, and continuous process improvement to support high-quality, patient-centered utilization management.

Job Type & Location

This is a Contract position based out of Redlands, CA.

Pay and Benefits

The pay range for this position is $47.00 - $65.00/hr. Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: Medical, dental & vision Critical Illness, Accident, and Hospital 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available Life Insurance (Voluntary Life & AD&D for the employee and dependents) Short and long-term disability Health Spending Account (HSA) Transportation benefits Employee Assistance Program Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on Sep 4, 2026.