Quality Review Nurse

Reporting to the Nurse Manager, Quality Review, and as a member of the Population Health and Quality department, the Quality Review Nurse (QRN) will support key clinical quality initiatives at SFHP. The QRN is part of SFHP Health Services Programs department which includes Population Health and Quality activities of the Plan. The QRN supports and leads clinical review activities within SFHP's Quality department by providing clinical input and oversight for the following quality areas:

• Grievance and Appeals
• Potential Quality Issues, including Provider Preventable Conditions
• Clinical Quality Initiatives

The QRN works closely with the Grievance and Appeals team and the SFHP Medical Director to ensure that clinical quality concerns are addressed in all grievances and appeals. As a member of SFHP's the Grievance Review Committee, the QRN supports the Grievance and Appeals team in ensuring that clinical concerns are addressed as part of grievance investigations.

Under the guidance of SFHP Medical Director, the QRN will support and manage the review and resolution of Potential Quality Issues (PQIs) and other clinical quality related initiatives. In addition, the QRN will support initiatives within the Quality Improvement Plan including those related to Healthcare Effectiveness Data and Information Set (HEDIS), CAHPS (Consumer Assessment of Healthcare Providers and Systems) metrics and other California Department of Healthcare Services (DHCS) metric performance.

This role is highly cross-functional and will partner closely with teams in both Health Services Operations and Health Services Programs departments as well as other areas of SFHP, especially Compliance and Customer Service.

Salary range: $114,000 - $134,000

Please note that while SFHP supports a hybrid work environment, you are required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office.

WHAT YOU WILL DO

Supports Quality Process:

• Support process improvement activities, and compiling in relation to department and quality metrics
• Review clinical quality processes and identifies workflow enhancements.
• Participate in the Quality Improvement Committee and UM Committee as appropriate.
• Document clinical reviews in care management system/tracking system.
• Participate in DHCS, DMHC, and NCQA audits.
• Work collaboratively with other SFHP departments.
• Plan and organize work to ensure operational efficiency and effectiveness of the department.
• Demonstrate expertise in researching and trouble-shooting issues related to clinical quality and policy.

Grievance and Appeals

• Review incoming grievance and appeals for clinical quality concerns and expedited status
• Document clinical reviews and provide clinical support and guidance to the Grievance and Appeals Team
• Provide clinical information and assessment of care during Grievance Review Committee (GRC).

Potential Quality Issues

• Identify, investigate and document potential quality issues (PQIs)
• Initiate and complete PQI investigations, including development of necessary clinical quality follow up and corrective action plans
• Support identification and reporting of Provider Preventable Conditions (PPC)

Clinical Quality Initiatives

• Provide clinical support to all quality activities.
• Assist with the operation of San Francisco Health Plan's quality improvement program.
• Assist in data collection and support the development of quality metric reporting.

WHAT YOU WILL BRING

• A Bachelor's degree in Nursing
• Registered Nurse license in the State of California without restriction, or LVN with 3 or more years health plan experience
• A current license to practice without restriction.
• At least 2 years of managed care experience.
• Competency in building relationships with providers. Knowledge of state and federal insurance programs.
• Experience with Medi-Cal and/or Department of Health Care Services (DHCS) regulations and standards.
• Proven organizational skills and project management skills especially in handling multiple projects effectively.
• Knowledge/experience with San Francisco safety net programs and providers.
• Clinical quality experience with knowledge of NCQA standards and audits.

WHAT WE OFFER

• Health Benefits
  
  
  
  • Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
  • Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
  • Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
  
  
  
  
• Retirement - Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
• Time off - 23 days of Paid Time Off (PTO) and 13 paid holidays.
• Professional development: Opportunities for tuition reimbursement, professional license/membership.

ABOUT SFHP

Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.

San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

San Francisco Health Plan is an E-Verify participating employer.

Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.

#LI-Hybrid

(Hybrid remote/in-office)

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