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Quality Review Nurse, San Francisco, CA

Organization: San Francisco Health Plan
Category: Nurse
Location: San Francisco, CA
Date Job Posted: May 6, 2022
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Quality Review Nurse

Department: Population Health
Office: HQ Beale Street
Location: San Francisco, CA

As the Quality Review RN (QR RN), you will support key clinical quality initiatives for San Francisco Health Plan (SFHP) and function as part of SFHP's Health Services Programs department. You will support and lead 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 QR RN 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 QR RN supports the Grievance and Appeals team in ensuring that clinical concerns are addressed as part of grievance investigations.

In addition, the QR RN will lead and support initiatives within the Quality Improvement Plan including those related to Healthcare Effectiveness Data and Information Set (HEDIS) metrics other and the 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.


Quality Process Support

  • Identify, develop and implement process improvement activities, and compile and analyze reports in relation to department and quality metrics.
  • Review clinical quality processes and identify workflow enhancements.
  • Document clinical reviews in SFHP's care management tracking system.
  • Participate in DHCS, DMHC, and NCQA audits.
  • Plan and organize work to ensure operational efficiency and effectiveness of the department.
  • Demonstrate expertise in researching and trouble-shooting issues related to clinical quality and policy.

Grievance and Appeals

  • Review incoming grievance and appeals for clinical quality concerns and expedited status.
  • Document clinical reviews and provide clinical support and guidance to the Grievance and Appeals Team.
  • Participate in case conferences and provide clinical information and assessment of care during Grievance Review Committee (GRC) meetings.
  • Works with Grievance and Appeals leadership to identify clinical quality trends that may require additional Plan oversight.

Potential Quality Issues

  • Identifies, investigates and documents potential quality issues (PQIs)
  • Under the guidance of SFHP Medical Director, initiates and completes PQI investigations, including development of necessary clinical quality follow up and corrective action plans
  • Supports identification and reporting of Provider Preventable Conditions (PPC)
  • Develops and conducts trainings as needed for member-facing departments.

Clinical Quality Initiatives

  • Identifies, implements and manages quality initiatives and projects to support clinical quality outcomes as outlined in SFHP’s Quality Improvement Plan
  • Provide clinical support to all quality activities.
  • Assists with the operation of San Francisco Health Plan’s quality improvement program.
  • Compiles and analyzes reports in relation to quality metrics


  • A Bachelor’s degree in Nursing
  • Registered Nurse license in the State of California without restriction.
  • At least 2 years of managed care experience.
  • Demonstrated ability 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.
  • Proven organizational skills and project management skills especially in handling multiple projects effectively.
  • Clinical quality experience, including experience with case reviews, NCQA, and auditing.
  • Knowledge and experience with health care quality models such as PDSA.


A competitive and robust compensation package, including:

  • Health benefits – several plan choices to cover you and your dependents medical, dental, vision needs
  • Retirement – Employer-matched CalPERS Pension and 401(a) plans, 457 Plan
  • Time off – 23 days of Paid Time Off (PTO) and 13 paid holidays
  • An opportunity to work in a vibrant atmosphere with the most amazingly talented people who are shaping the future of healthcare!
  • The chance to make a difference in the lives of many San Francisco residents!


Established in 1997, San Francisco Health Plan (SFHP) is a 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 135,000+ 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 requires employees provide proof of an up-to-date vaccination against COVID-19 as defined by the San Francisco Department of Public Health. Reasonable accommodations will be considered on a case-by-case basis for exemptions to this requirement subject to the applicable law[s].

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.

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