What are the responsibilities and job description for the Nurse Manager, Prior Authorization position at SF Health Plan?
Reporting to the Director of Clinical Operations, the Nurse Manager, Prior Authorizations, provides clinical and operational leadership to the Prior Authorizations (PA) team within the Utilization Management (UM) function. You will manage a team of registered nurses and clinical staff responsible for prior authorization reviews, ensuring determinations are on time, clinically appropriate, and compliant with Medi-Cal, DHCS, and SFHP standards.
Please note that while SFHP supports a hybrid work environment, you are required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office.
Salary: $150,000 to $170,000 annual
WHAT YOU WILL DO:
- Manage a team of nurses and clinical staff responsible for prior authorization reviews, ensuring accurate application of UM criteria and timely completion of determinations.
- Define, communicate, and track individual and team goals aligned with departmental goals; ensure deliverables are met.
- Provide hands-on coaching and mentorship to staff.
- Monitor performance metrics, workload balance, and service quality; identify opportunities for development and process improvement.
- Conduct regular check-ins, providing meaningful feedback and recognition.
- Oversee daily operations of the PA team, including triage, documentation, and compliance with turnaround time standards.
- Ensure consistent application of evidence-based criteria (e.g., InterQual, MCG, SFHP policies, Medi-Cal and Medicare guidelines).
- Collaborate with UM leadership and Medical Directors to design and implement UM protocols, workflows, and staff training.
- Analyze authorization trends and performance data; develop action plans to address efficiency, accuracy, or quality gaps.
- Manage clinically related authorization and claims issues, escalating appropriately and ensuring timely resolution.
WHAT YOU WILL BRING:
- Valid, unrestricted Registered Nurse (RN) or Nurse Practitioner (NP) license in the State of California.
- Bachelor's degree in Nursing or related field required.
- Minimum of 4 years of clinical experience in a healthcare setting required; experience in managed care, case management, resource management, or utilization review, preferred.
- 2 to 4 years of supervisory or lead experience required.
- Experience with Medi-Cal, Medicare, DHCS, DMHC, and NCQA regulations preferred.
WHAT WE OFFER:
- 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.
ABOUT SFHP:
Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000 members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.
San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
San Francisco Health Plan is an E-Verify participating employer.
Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.
#LI-Hybrid
(Hybrid remote/in-office)
Salary : $150,000 - $170,000