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.
WHAT YOU’LL DO
WHAT YOU’LL BRING
WHO WE ARE
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.