Quality Review Nurse (RN)

US-CA-San Francisco
Job ID
Health Services
Regular Full-Time




In this mission-critical role, you will be responsible for the review, documentation, and management of clinical grievances, clinical appeals, Potential Quality Issues (PQI), and other clinical quality related initiatives. You will ensure the quality processes align with the utilization management processes and regulatory compliance is met. You will partner closely with the Health Improvement department to manage the flow of clinical appeals and grievances and to escalate to the medical directors as needed. Reviews the clinical appeal records and applies SFHP-approved medical necessity criteria and policies. The scope of duties also include partnering with the Clinical Outreach Nurse with oversight and monitoring CM and UM activities of non-delegated medical groups and internal staff. You will work collaboratively with all levels and departments of the SFHP organization, and represent the Utilization Management Unit.



  • Review, track, document, and manage clinical appeals and grievances. 
  • Work closely with the Medical director to resolve Potential Quality Issues (PQI).
  • Comply with clinical appeal and grievance accreditation and regulatory standards.
  • Review clinical quality processes and identify workflow enhancements.
  • Conduct quarterly review of internal UM and CM cases and provide opportunities for improvement to leadership. 
  • Collaborate with Clinical Outreach Nurse with monitoring and oversight activities.
  • Facilitate the Interrater Reliability program.
  • Participate in DHCS, DMHC, and NCQA audits.
  • Audit SFHP authorization determinations against NCQA standards and SFHP policies and procedures and adheres to our agreements with our delegated groups.
  • Perform audits and address audit findings, such as on authorization determinations. 
  • Actively contribute toward Program and Process improvements and goals and continuously improves the managed care process and pipeline of new opportunities.
  • Work collaboratively with Provider Network Operations, Compliance, Claims, and Health Improvement departments.
  • Demonstrate expertise in researching and trouble-shooting issues related to clinical quality and policy.
  • Participate in the development and review of policies and procedures.
  • Participate in the Quality Improvement Committee and UM Committee.


  • A Bachelor’s degree in Nursing
  • A current CA RN license to practice without restriction.
  • At least 2 years of managed care experience required.
  • At least 2 years of UM or QM experience preferred.
  • Competency in building relationships with providers locally.
  • Knowledge of state and federal insurance programs.
  • Experience with Medi-Cal and/or Department of Health Care Services 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.




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 145,000+ 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 an Equal Opportunity Employer (EOE M/F/D/V)

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.




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