San Francisco Health Plan · 3 weeks ago
Director, Clinical Operations (Utilization Management)
San Francisco, CA
Full-time
Hybrid
Director/Executive
$195K/yr - $215K/yr
7+ years expSan Francisco Health Plan (SFHP) is an award-winning managed care health plan dedicated to providing affordable healthcare coverage. The Director of Clinical Operations will lead and oversee the Utilization Management program, ensuring compliance and operational efficiency while managing a clinical and administrative team.
Health Care
Responsibilities
Lead daily operations of the Utilization Management department, including prior authorization, concurrent review, and discharge planning functions
Manage departmental structure, staffing, and workflows to ensure determinations and high-quality service delivery
Manage and develop the UM leadership team, ensuring clarity of roles, accountability, and professional growth
Establish department performance goals, dashboards, and quality metrics; monitor results and take corrective action
Maintain departmental policies and procedures consistent with DHCS, DMHC, and NCQA requirements
Ensure the UM program operates in full compliance with applicable regulations and accreditation standards
Oversee UM delegation oversight activities, including annual medical group audits, review of corrective action plans (CAPs), and preparation of audit documentation
Collaborate with Compliance and Quality teams to maintain readiness for internal and external reviews
Partner with the Medical Directors to ensure clinical consistency in decision-making and adherence to SFHP policies
Analyze utilization trends and performance data to identify opportunities for cost reduction and improved member outcomes
Lead process redesign and workflow optimization efforts to improve efficiency and reduce administrative burden
Partner with Claims, Performance Process Improvement, and IT to enhance automation, data accuracy, and integration between authorization and claims systems
Support programs to align UM practices with Care Management and Population Health programs, ensuring seamless transitions of care
Develop, implement, and monitor corrective and preventive action plans to address operational gaps our audit findings
Be an operational liaison between SFHP and contracted hospitals, IPAs, and providers regarding UM policies and authorization processes
Participate in internal and external committees, including the Utilization Management Committee and Clinical Oversight Committee
Provide subject matter expertise for organizational projects involving utilization policy, benefits implementation, or network performance
Communicate with senior leadership and cross-department partners on UM outcomes, challenges, and strategic priorities
Develop and manage the UM department budget, monitoring expenditures and aligning resource use with program goals
Use data analytics and financial reports to assess utilization patterns and support affordability programs
Collaborate with Finance and Analytics teams to prepare forecasts, reports, and regulatory submissions related to UM activity
Promote a culture of collaboration, accountability, and learning; provide mentorship, coaching, and professional development for UM managers and staff
Ensure onboarding, training, and continuing education for all employees, and partner with HR to recruit, retain, and develop top talent
Qualification
Required
Current, unrestricted California Registered Nurse (RN) license
Bachelor's degree in Nursing or a related health field required; Master's degree in Nursing, Health Administration, or related discipline
Minimum of 7 years of progressively responsible management experience in Utilization Management or related managed care operations, including leadership of managers or multi-level teams
Experience designing and implementing strategic programs that improve efficiency, compliance, and quality
Knowledge of California and federal insurance programs, Medi-Cal/Medicaid experience
Experience leading teams and representing operational areas in enterprise-level strategy forums
Benefits
Health Benefits
Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
Retirement – Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
Time off – 23 days of Paid Time Off (PTO) and 13 paid holidays.
Professional development: Opportunities for tuition reimbursement, professional license/membership.
Company
San Francisco Health Plan
San Francisco Health Plan is a community health plan that provides affordable & high-quality health care coverage for San Franciscans.
201-500 employees
H1B Sponsorship
San Francisco Health Plan has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (2)
2024 (6)
2023 (3)
2022 (3)
2021 (11)
2020 (6)
Funding
Current Stage
Growth StageLeadership Team
John F. Grgurina Jr.
CEO
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