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%.
