Director of Utilization Management - PACE

We truly value our employees and are committed to their success! We offer long-term employment opportunities with job stability, as well as support and encouragement for career growth and advancement. Our comprehensive benefits package includes Health, Dental, and Vision insurance, Paid Time Off, 9 Paid Holidays, a 403(b) Retirement Plan with company matching, and company-paid Life Insurance. Join our team and experience a workplace culture that fosters teamwork, growth, and support!

Los Angeles Jewish Health has been a trusted provider of senior healthcare for over 100 years, offering a wide range of services that prioritize excellence and Jewish values. We serve more than 4,000 seniors across our San Fernando Valley campuses, delivering personalized care tailored to each individual’s needs, from independent living to specialized healthcare programs.

The Brandman Centers for Senior Care (BCSC), a Program of All-inclusive Care for the Elderly (PACE), provides high-quality, comprehensive healthcare services. We are a program of Los Angeles Jewish Health, renowned for providing quality care to vulnerable seniors.

The responsibilities of the Director of Utilization Management include, but are not limited to: 

Responsibilities:

• Leads the Utilization Management (UM) program to ensure appropriate, cost-effective, and high-quality care for PACE participants.
• Oversees care authorization, service utilization, and compliance with regulatory and organizational standards.
• Collaborates with interdisciplinary team (IDT) to align care decisions with participant-centered goals.
• Develop, implement, and continuously improve UM strategies, policies, and procedures.
• Align utilization practices with PACE model of care, focusing on frail, elderly populations.
• Monitor trends in service utilization and implement interventions to optimize quality outcomes and utilize resources appropriately for best outcomes.
• Provide clinical leadership for medical necessity determinations and authorization processes.
• Ensure appropriate level of care decisions across settings (home care, adult day health, inpatient, SNF).
• Review complex or high-cost cases and provide guidance on care planning.
• Ensure compliance with CMS, state Medicaid, and PACE regulatory requirements.
• Maintain audit readiness and oversee internal/external audits related to utilization management.
• Ensure documentation standards meet legal and accreditation requirements.
• Partner with physicians, nurses, social workers, and therapists within the IDT.
• Support care coordination and transitions of care to reduce avoidable hospitalizations.
• Participate in care planning meetings and case conferences.
• Analyze utilization data, including hospital admissions, readmissions, LOS, and service patterns.
• Develop and track KPIs and dashboards for UM performance.
• Lead initiatives to improve quality metrics and reduce unnecessary utilization.
• Lead, mentor, and evaluate UM staff including nurses and coordinators.
• Provide ongoing training on UM processes, clinical guidelines, and compliance requirements.
• Foster a culture of accountability, collaboration, and continuous improvement.
• Collaborate with contracted providers, hospitals, and post-acute facilities.
• Evaluate provider performance related to utilization and quality outcomes.
• Support contract negotiations with utilization considerations.
• Performs all other duties as assigned. 

Education & Experience:

• Degree and diplomas: Active RN license required; advanced degree (MSN, MHA, MPH) preferred.
• Certificates, Licenses: RN currently licensed by the California Board of Registered Nursing.  Verification of completion of CPR (BLS) and first aid training.  TB screening and successful completion of a health examination by a health care provider is required for employment. Must have valid California driver’s license.
• Experience:
• 7–10+ years of clinical and/or utilization management experience, preferably in geriatrics or managed care.
• 3–5+ years of leadership experience.
• Strong knowledge of CMS, Medicaid, and PACE regulations.
• Experience with value-based care and population health models.
• Knowledge of and/or experience with Managed Care Health plans, Medi-Cal/Medicaid, and/or Medicare
• Bilingual preferred.
• Skills/Aptitudes: Nursing knowledge and skills necessary to manage complex clinical situations.  Ability to provide care for the frail elderly.  Ability to work independently and within an Interdisciplinary Team.  Good organizational and supervisory skills.  Ability to handle complex interpersonal and clinical situations.

Join Los Angeles Jewish Health and make a meaningful impact in the lives of seniors in our community. Become part of our compassionate team, dedicated to providing exceptional care and support. Apply today and start making a difference!