San Francisco Health Plan
Quality Review Nurse
San Francisco Health Plan, San Francisco, California, United States, 94199
Overview
Reporting to the Nurse Manager, the Quality Review Nurse (QRN) will support key clinical quality initiatives at San Francisco Health Plan (SFHP). The QRN is part of SFHP’s Health Services Programs Department and leads clinical review activities within the Quality Department, providing oversight for grievance and appeals, potential quality issues (PQIs), and related clinical quality initiatives. Salary range: $114,000 – $134,000. Hybrid work: required onsite in the Downtown San Francisco office, minimum 4 days per month. Responsibilities
Support process improvement activities and compile quality metrics for the department. Review clinical quality processes, identify workflow enhancements, and document reviews in the care management system. Participate in the Quality Improvement Committee, Utilization Management Committee, and DHCS/DMHC/NCQA audits as appropriate. Work collaboratively with SFHP departments (Health Services Operations and Programs, Compliance, Customer Service).
Review incoming grievance and appeals for clinical quality concerns, provide clinical support and guidance to the Grievance and Appeals Team, and assess care during Grievance Review Committee meetings.
Identify, investigate, and document PQIs, initiate and complete investigations, develop corrective action plans, and support reporting of Provider Preventable Conditions (PPC).
Provide clinical support to all quality activities, assist with the operation of SFHP’s quality improvement program, and support data collection and quality metric reporting.
Qualifications
A Bachelor’s degree in Nursing. Registered Nurse (RN) license in California without restriction, or Licensed Vocational Nurse (LVN) with at least 3 years of health plan experience. At least two years of managed care experience. Competency building relationships with providers and knowledge of state and federal insurance programs. Experience with Medi‑Cal and/or Department of Health Care Services (DHCS) regulations and standards. Proven organizational and project management skills, especially in handling multiple projects effectively. Knowledge of San Francisco safety net programs and providers. Clinical quality experience with NCQA standards and audits.
What We Offer
Health benefits: medical (Kaiser and Blue Shield of California plans), dental (basic or enhanced with orthodontics), and vision (Vision Service Plan). Retirement: CalPERS pension and 401(a) matched plans, 457 plan. Time off: 23 days PTO and 13 paid holidays. Professional development: tuition reimbursement, professional license/membership opportunities.
Equal Opportunity Employer
San Francisco Health Plan is an E‑Verify participating equal opportunity employer committed to a work environment that supports, inspires, and respects all individuals. We comply with the San Francisco Fair Chance Ordinance and consider qualified applicants with arrest and conviction records. Hiring priority is given to candidates residing in the San Francisco Bay Area and California.
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Reporting to the Nurse Manager, the Quality Review Nurse (QRN) will support key clinical quality initiatives at San Francisco Health Plan (SFHP). The QRN is part of SFHP’s Health Services Programs Department and leads clinical review activities within the Quality Department, providing oversight for grievance and appeals, potential quality issues (PQIs), and related clinical quality initiatives. Salary range: $114,000 – $134,000. Hybrid work: required onsite in the Downtown San Francisco office, minimum 4 days per month. Responsibilities
Support process improvement activities and compile quality metrics for the department. Review clinical quality processes, identify workflow enhancements, and document reviews in the care management system. Participate in the Quality Improvement Committee, Utilization Management Committee, and DHCS/DMHC/NCQA audits as appropriate. Work collaboratively with SFHP departments (Health Services Operations and Programs, Compliance, Customer Service).
Review incoming grievance and appeals for clinical quality concerns, provide clinical support and guidance to the Grievance and Appeals Team, and assess care during Grievance Review Committee meetings.
Identify, investigate, and document PQIs, initiate and complete investigations, develop corrective action plans, and support reporting of Provider Preventable Conditions (PPC).
Provide clinical support to all quality activities, assist with the operation of SFHP’s quality improvement program, and support data collection and quality metric reporting.
Qualifications
A Bachelor’s degree in Nursing. Registered Nurse (RN) license in California without restriction, or Licensed Vocational Nurse (LVN) with at least 3 years of health plan experience. At least two years of managed care experience. Competency building relationships with providers and knowledge of state and federal insurance programs. Experience with Medi‑Cal and/or Department of Health Care Services (DHCS) regulations and standards. Proven organizational and project management skills, especially in handling multiple projects effectively. Knowledge of San Francisco safety net programs and providers. Clinical quality experience with NCQA standards and audits.
What We Offer
Health benefits: medical (Kaiser and Blue Shield of California plans), dental (basic or enhanced with orthodontics), and vision (Vision Service Plan). Retirement: CalPERS pension and 401(a) matched plans, 457 plan. Time off: 23 days PTO and 13 paid holidays. Professional development: tuition reimbursement, professional license/membership opportunities.
Equal Opportunity Employer
San Francisco Health Plan is an E‑Verify participating equal opportunity employer committed to a work environment that supports, inspires, and respects all individuals. We comply with the San Francisco Fair Chance Ordinance and consider qualified applicants with arrest and conviction records. Hiring priority is given to candidates residing in the San Francisco Bay Area and California.
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