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The Supervisor, Utilization Management & Appeals (After-Hours & Overnight Coverage) is responsible for overseeing daily Utilization Management (UM) and Appeals operations while also providing hands-on overnight, weekend and holiday coverage. This role combines clinical leadership with operational execution to ensure timely, accurate, and compliant utilization and appeal workflows. The Supervisor provides guidance and oversight to UM nurses, supports complex case preparation, ensures regulatory compliance, and maintains operational continuity.

This position plays a critical role in ensuring high-quality clinical documentation, effective workload management, and coordination with medical directors, providers, and internal stakeholders.

Essential Functions:

Leadership & Operations

• Supervise daily activities of UM and Appeals staff, including nurses.
• Monitor workloads, productivity, and performance metrics to maintain service-level and regulatory compliance.
• Provide clinical oversight and coaching on complex UM and Appeals cases; escalate to medical directors as appropriate.
• Train, mentor, and evaluate team members; participate in hiring, corrective action, and performance management processes.
• Develop, implement, and maintain standard operating procedures (SOPs) across UM and Appeals workflows.
• Participate in audits, reporting, and continuous performance improvement initiatives.
• Collaborate cross-functionally with medical directors, case management, providers, and client stakeholders to ensure appropriate care and avoid unnecessary utilization.
• Ability to work After-Hours & Overnight Coverage

Clinical & Overnight Coverage

• Provide overnight, weekend, and holiday operational coverage to maintain continuous UM and Appeals workflows.
• Manage and process work queues, including screening requests, creating authorizations, routing cases, and generating member and provider notifications.
• Prepare accurate and thorough clinical summaries and documentation for physician review (non-decisional).
• Review case data for completeness, accuracy, and regulatory alignment prior to submission.
• Support Appeals intake, screening, and case preparation in accordance with appeal protocols.
• Work independently during overnight and weekend hours with minimal supervision, maintaining productivity during low call-volume periods through assigned tasks.

Compliance & Knowledge Management

• Ensure adherence to federal and state regulations, NCQA/URAC standards, and payer-specific UM and Appeals requirements.
• Maintain strong working knowledge of InterQual and/or MCG criteria.
• Stay current on healthcare regulations, utilization trends, and evidence-based clinical guidelines.
• Ensure consistent application of UM and Appeals policies across all shifts.

Competencies:

• Utilization management oversight
• Medical necessity
• Clinical operations supervision
• Regulatory compliance
• Workflow management
• Performance improvement
• Appeals, grievances, and denials coordination
• Policy and procedure implementation
• Productivity and KPI monitoring
• Process improvement
• Training and staff development
• Customer service excellence
• Problem solving
• Proficient in Microsoft office suite.
• Ability to thrive in a fast-paced, evolving healthcare environment.

Required education and experience:

• Active, unrestricted Registered Nurse (RN) license in California.
• Minimum of 5 years of Utilization Management experience and 2 years of Appeals experience.
• At least 2 years of leadership or supervisory experience in a UM or Appeals setting.
• Strong understanding of UM and Appeals processes, including intake, screening, and documentation.
• Experience managing or supporting remote clinical teams.
• Familiarity with Medicare, Medicaid, and commercial payer requirements.
• Excellent written communication, attention to detail, and organizational skills.
• Ability to work independently during overnight and weekend shifts
• Utilization management: 5 years (Required)
• Appeals: 2 years (Required)

Preferred education, certifications and/or experience:

• Bachelor of Science in Nursing (BSN)
• Consulting or project-based healthcare experience
• UM leadership: 2 years (Preferred)
• RN license in California (Required)

Physical Requirements/Work environment:

• Fully remote role with occasional travel (less than 5%).
• Must maintain a secure home office environment with the required equipment.
• Prolonged periods of sitting and computer use.
• Ability to communicate clearly in both written and verbal formats.
• Internet Speed Minimum of 100 Mbps download and 10–20 Mbps upload
• Typing/data entry of 30 WPM

Work Schedule:

• Day and overnight coverage, including:
• Weekdays: 5:00 PM – 8:00 AM (Pacific time)
• Weekends: 8:00 AM Saturday – 8:00 AM Monday (Pacific time)
• Required holidays and on-call rotation