Robert J. Potter

Visionary healthcare executive with over 15 years of experience driving organizational transformation and strategic growth in managed care. Proven track record of developing high-performing teams, implementing innovative solutions, and ensuring regulatory compliance. Expertise in quality improvement, Medicare Stars management, Managed Care (Medi-Cal and Medicare), and financial optimization.

Known for unifying diverse stakeholders, leading through crises, and building strong partner relationships in complex matrix organizations. Committed to advancing health equity and driving technological innovation in healthcare delivery.

Manager, Utilization Management - Chinese Community Health Plan - San Francisco, CA

(2026-04)

Officially titled Manager of Utilization Management while functioning at the department-head level, with direct accountability for UM departmental operations, regulatory compliance (DMHC, CMS, NCQA), and clinical operations strategy across Commercial and Medicare product lines. Lead a team of 7 nurse reviewers and support staff, reporting directly to the Chief Medical Officer.

• Authored an executive-level business case for migrating the utilization management platform from Meditrac to Essette, evaluating cost, workflow efficiency, and regulatory reporting capability.
• Developed and sequenced a multi-year cost-savings strategy through 2027, prioritizing InterQual reviewer retraining, reinstatement of concurrent review, delegate relationship development, and Part B / specialty drug utilization management.
• Led the update of preventive care coverage determination guidelines for the 2026 plan year to align departmental policy with current regulatory and clinical standards.
• Produced an executive business case for unifying Utilization Management, Case Management, Population Health, Appeals & Grievances, and Provider Disputes under integrated clinical operations leadership.
• Structured and managed vendor and consulting engagements supporting departmental initiatives, including a California-compliant consulting services agreement.

Utilization Management Supervisor, Inpatient - Partnership Health Plan of California - Fairfield, CA

(2025-03 - 2026-04)

Provided daily supervision and leadership to utilization management staff while ensuring departmental compliance with Title 22, the Medi-Cal Provider Manual, DMHC and CMS regulatory requirements, and medical necessity criteria across multiple product lines. Led a cohesive team focused on achieving high levels of productivity, accuracy, and quality in member care coordination.

• Supervised daily operations including staff scheduling, timecard management, performance evaluation, and work direction to meet business requirements and regulatory standards.
• Conducted performance reviews and participated in interviewing, hiring, and comprehensive onboarding for new team members.
• Maintained active oversight of inbound and outbound provider reporting while managing patient-specific documentation in Partnership systems and databases.
• Facilitated meetings with community provider partners as part of the UM process, developing positive relationships to optimize member care and provider satisfaction.
• Audited medical records for accuracy and workflow evaluation, providing staff feedback and identifying process improvement opportunities.
• Researched and resolved provider issues and barriers, ensuring successful outcomes through superior customer service.
• Reviewed and recommended updates to department policies, procedures, and desktop protocols to enhance operational efficiency.
• Participated in multidisciplinary committees and workgroups supporting Partnership's strategic initiatives and organizational goals.
• Evaluated appropriateness of care through interpretation of benefits and medical necessity criteria while managing an assigned caseload in addition to supervisory duties.

RN Supervisor - Telecare Corporation - Modesto, CA

(2024-07 - 2025-04)

Provided clinical leadership and oversight for a 16-bed acute psychiatric facility.

• Directed nursing operations and crisis intervention protocols in an acute psychiatric setting.
• Led an interdisciplinary team in the delivery of complex psychiatric care.
• Ensured regulatory compliance and quality standards in mental health service delivery.
• Managed clinical risk assessment and intervention strategies.
• Coordinated with community partners for continuity of psychiatric care.

Manager of Utilization Management - P3 Health Partners - Stockton, CA

(2024-02 - 2024-12)

• Spearheaded strategic service enhancement initiatives across California, resulting in a 15% improvement in patient satisfaction scores.
• Implemented a proprietary utilization review framework, reducing unnecessary admissions by 20% and saving $2M annually.
• Led digital transformation of utilization management processes, improving efficiency by 30%.
• Developed and executed a provider education program, increasing adherence to best practices by 25%.

Travel Nurse Specialist - Aya Healthcare

(2023-09 - 2024-02)

• Served as a specialized 1:1 nurse for complex care management.
• Provided comprehensive care coordination for high-risk patient populations.
• Developed and implemented individualized care plans in collaboration with multidisciplinary teams.
• Established evidence-based protocols for chronic disease management.
• Achieved excellence in patient outcomes through proactive care planning.

Supervisor of Quality Improvement - Health Net, LLC - Sacramento, CA

(2021-05 - 2023-02)

• Drove KPI improvements, resulting in a 10% increase in HEDIS scores and $5M in quality bonuses.
• Established and led a pilot program team, remediating lower-performing partner care gaps and improving overall quality ratings by 2 stars.
• Implemented data analytics tools, enabling real-time performance tracking and proactive intervention strategies.

Delegation Oversight Auditor - Health Net, LLC - Sacramento, CA

(2019-11 - 2021-05)

• Conducted compliance and risk assessments for delegate partners, ensuring 100% regulatory compliance.
• Developed corrective action plans that improved delegate performance by an average of 30%.
• Led crisis management efforts during COVID-19, rapidly implementing telehealth solutions across the network.

Per Diem Unit Manager - Avalon Health Care

(2021-07 - 2022-05)

• Provided strategic oversight of nursing operations and quality management.
• Directed clinical operations and staff development for multiple nursing units.
• Implemented evidence-based care protocols resulting in improved patient outcomes.
• Optimized staffing models and resource allocation to ensure operational efficiency.
• Established quality metrics and monitoring systems for performance improvement.

Discharge Planner - Molina Healthcare

(2015-04 - 2017-04)

• Led utilization management initiatives and care coordination programs.
• Developed and implemented comprehensive discharge planning protocols.
• Optimized care transitions, resulting in reduced readmission rates.
• Ensured compliance with state and federal regulations while maintaining cost-effectiveness.
• Established partnerships with post-acute care providers to enhance care continuity.

Prior Authorization Nurse - Health Plan of San Joaquin

(2013-02 - 2015-03)

• Directed utilization management operations and process improvement.
• Developed standardized authorization protocols improving operational efficiency.
• Led implementation of a new authorization management system.
• Established quality control measures ensuring regulatory compliance.
• Managed complex case reviews and appeals processes.

Owner / Administrator - Rockingham Assisted Living

(2008-12 - 2014-01)

Founded and led full-scale operations for three assisted living facilities.

• Established comprehensive operational infrastructure and quality management systems.
• Developed and implemented regulatory compliance programs.
• Managed a $3M+ annual budget and 20+ staff members.
• Achieved and maintained state licensing compliance and Medicaid certification.
• Created an innovative fall prevention program reducing incidents by 25%.

Doctorate in Healthcare Administration - Organizational Leadership - Grand Canyon University (2027)

Master of Business Administration - Healthcare Systems Management - Grand Canyon University

Bachelor of Science - Nursing - Nightingale College

Bachelor of Science - Grand Canyon University