Reporting to Manager, Clinical Operations Administration, the Clinical Quality and Oversight Nurse is responsible for ensuring utilization management (UM) activities comply with regulatory and accreditation requirements (CMS, DHCS, DMHC, NCQA). You will provide oversight of both internal UM processes and delegated entities to ensure consistent application of clinical criteria, adherence to regulatory and contractual standards, and delivery of high-quality, member-centered care. You will partner with the Compliance and Provider Network Management departments to complete all UM oversight audits and are responsible for establishing and strengthening relationships with delegated entities to ensure tactical alignments and regulatory compliance are met

Please note that while SFHP offers a hybrid work environment, you must be flexible and available to work onsite at least 4 days per month, as determined by your manager.

Salary: $55 - $65 per hour

WHAT YOU WILL DO:

• Performs delegation oversight audits of UM functions including policies, programmatic documents, case files, and reports to validate compliance with contract requirements, regulations, and accreditation standards.
• Acts as a liaison between SFHP Clinical Operations team and the delegated UM entities and ensure delegates inquiries are effectively handled and promptly addressed.
• Reviews authorization decisions for timeliness, appropriateness, and clinical accuracy.
• Tracks and trends performance, identifies gaps, issues and monitors corrective actions.
• Prepares and presents audit summary reports for the Utilization Management Committee (UMC) and Provider Network Outreach Committee (PNOC).
• Interprets regulatory requirements (DHCS, DMHC, and CMS) and accreditation standards (NCQA), participates in the development of policies and procedures, and prepares comprehensive audits tools and scoring sheets.
• Conducts annual full scope audits, quarterly limited scope audits, and monthly review of delegate reports, and provides feedback and/or training as needed.
• Conducts internal audits on a quarterly basis and assists in addressing any findings.
• Participates in the review of the Delegation Grid.
• Participates in DHCS, DMHC, NCQA, and CMS audits.
• Actively contributes toward program goals, process improvements, and continuously improves managed care processes.
• Demonstrates expertise in researching and troubleshooting issues related to clinical authorization and policy.
• Plans and organizes work to ensure operational efficiency and effectiveness of the department

WHAT YOU WILL BRING:

• A current State of California RN license to practice without restriction.
• At least 2 years of utilization management experience, required.
• At least 2 years of audit and oversight experience, required.
• At least 2 years of clinical experience, preferred.

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)