Quality Review Nurse
San Francisco Health Plan
As a member of the Population Health and Quality department, the Quality Review Nurse (QRN) will support key clinical quality initiatives at San Francisco Health Plan (SFHP). The QRN is part of SFHP Health Services 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.
Reporting to the QRN Manager and 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 collaborative, partnering 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.
WHAT YOU WILL DO
- Support Quality Process:
- Support process improvement activities, and compiling in relation to department and quality metrics
- Review clinical quality processes and identifies workflow enhancements.
- Participates in the Quality Improvement Committee and UM Committee as appropriate.
- Document clinical reviews in care management system/tracking system.
- Actively contribute toward program and process improvements and goals; continuously improve the managed care process.
- Participate in DHCS, DMHC, and NCQA audits.
- Grievance and Appeals
- Review incoming grievance and appeals for clinical quality concerns and expedited status.
- Document clinical reviews and provides clinical support and guidance to the Grievance and Appeals Team.
- Participate in case conferences. Provide clinical information and assessment of care during Grievance Review Committee (GRC). .
- Potential Quality Issues
- Identify, investigate and document potential quality issues (PQIs).
- Under the guidance of SFHP Medical Director, 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 reporting in relation to quality metrics
WHAT YOU WILL BRING
- 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.
- A Bachelor’s degree in Nursing desired
- At least 2 years of managed care experience.
- Knowledge/experience with San Francisco safety net programs and providers.
- 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, required.
- Proven organizational skills and project management skills especially in handling multiple projects effectively.
- Clinical quality experience. NCQA and auditing experience preferred
- Knowledge and experience with health care quality models such as PDSA preferred.
- Medical Plans: You’ll have a choice of medical plans, including options from Kaiser and Blue Shield of California. Employee-only coverage in the the HMO plans are currently available at no cost and dependent coverage is 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 at no cost.
- Time Off: 23 days of Paid Time Off and 12 observed company holidays.
- Professional development: Opportunities for tuition reimbursement, professional license/membership.
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 170,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.
San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports and respects all individuals and in which our 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.