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, the Quality Review Nurse is not required to meet the minimum in-office requirement of 4x / month but is required to attend company meetings and other in-person events at Manager's discretion.

WHAT YOU WILL DO

Supports Quality Process :

Grievance and Appeals

Potential Quality Issues

Clinical Quality Initiatives

WHAT YOU WILL BRING

WHAT WE OFFER

Health Benefits

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)

Please see job description

PI278849857

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