Clinical Quality and Oversight Nurse

SF Health Plan • San Francisco, CA

9d • Hybrid

About The Position

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 supports a hybrid work environment, the Clinical Quality and Oversight 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.

Requirements

• A current and active California LVN licensed required
• At least 2 years of utilization management experience, required.
• At least 2 years of audit and oversight experience, required.

Nice To Haves

• State of California RN license to practice without restriction is preferred
• At least 2 years of clinical experience, preferred.

Responsibilities

• 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

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed