Pace Utilization Manager Rn; Modesto

Job Category: Clinical Supervisor

Requisition Number: PACEU
004542

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• Posted :
  March 3, 2026
• Full-Time

Showing 1 location

Modesto, CA 95355, USA

Provides utilization management functions as a part of the Program for All Inclusive Care for the Elderly benefits management system. This includes providing utilization review and management for all acute, post-acute, and outpatient services as well as performing the identification, analysis and resolution of resource utilization outliers consistent with established protocols, policies and procedures. Serves as a liaison between network providers and the CV PACE clinical and Interdisciplinary Teams (IDT) related to participant assessment, care planning, and care coordination to assure participants progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

Works closely with finance and claims adjudication teams for the purposes of care management, data analysis and practice, and system performance.

Schedule
:
Monday – Friday, 8:00am – 5:00pm.

Compensation
:

Golden Valley Health Centers offers excellent benefits including Medical: (0 Deductible / $2,000 Individual; $4,000 Family Out-of-Pocket Max), excellent PPO coverages;
Dental;
Vision; 403(b) with match, FSA plans, gym discounts, and so much more!

• Performs concurrent and retrospective utilization management reviews and functions; collect, analyze, and report outcomes to internal and external stakeholders.
• Responsible for the development, review, revision, and implementation of utilization management policies and protocols that ensure valid utilization review outcome measures.
• Collaborate with the PACE Medical Director, Health Plan Director, Director of Center Operations, Clinical Manager and PCPs ensuring all participant hospitalizations are authorized for the correct status (inpatient, outpatient short stay, observation status) consistent with the participant’s severity of illness.
• Collaborate with the Medical Director, Health Plan Director, Director of Center Operations, Clinical Manager and center IDTs to ensure appropriate initial and ongoing service authorization for post-acute participant stays.
• For all level of care and service authorization decisions, communicates the information necessary to all stakeholders assuring appropriate claim adjudication and payment.
• Performs concurrent review process in order to effectively manage the length of inpatient and post-acute stays consistent with participant goals of care and care plan.
• Prepare succinct, written clinical case summaries that include rationale for the authorized service and payment status.
• Serve as a resource for CV PACE PCPs and network provider care managers to ensure consistent and accurate level of care and service authorization for appropriate claim submission and payment.
• Collaborate with the Medical Director, Director of center Operations, Clinical Manager and Health Plan Director to manage the provider claim denial appeal policy and process.
• Document all participant and staff interactions in the electronic medical record consistent policy;
• Maintains professional relationships with internal and external stakeholders, including provider community, while identifying opportunities for utilization management process improvement;
• Develop and implement strategic plans, which will have a direct impact on appropriate resources utilization and improved patient outcomes.
• Identify high-risk patients via inpatient rounds, provider referral patterns, utilization management referrals, and disease registry reporting mechanisms, and refer to appropriate PACE site medical leadership.
• Maintains up to date knowledge of PACE rules and regulations governing utilization management processes; implements approved policies, procedures and workflows.
• Ensures timely referral processing by tracking within the authorization system and coordinating with internal and external stakeholders for timely referral processing.
• Responsible for daily coverage needs for inpatient concurrent reviews, discharge planning, utilization management…