San Francisco Health Plan

  • Quality Reviewer, Care Management

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

    Bring your passion for quality of care and compliance oversight to San Francisco Health Plan to help those most in need!


    As the Care Management (CM) Quality Reviewer, you will work in partnership with the Director and Manager of Care Management to ensure a high quality of care management services are being provided to our members throughout San Francisco Health Plan (SFHP). You will be responsible for (in collaboration with the Manager, Delegation Oversight), to complete SFHP’s medical group audits in the areas of case management and coordination of care. You will also provide oversight and monitoring of all Community Based Care Management Entities (CB-CMEs) who are providing the new Medi-Cal Health Homes benefit and act as a liaison for SFHP’s delegated groups, providers and CB-CMEs to address any care management and coordination of care questions or concerns. 




    • Act as a liaison between the SFHP Care Management Department, the contracted provider groups, clinics and other external care management providers SFHP partners with.
    • Responsible for reviewing and understanding all care management and coordination of care contract and regulatory requirements from the Department of Health Care Services (DHCS), the Department of Managed Health Care (DMHC) and the National Committee on Quality Assurance (NCQA).
    • Using medical group data, you will prepare and track program performance, utilization and quality review reports for contracted groups and SFHP, and follows up on any related corrective actions.
    • Complete contracted medical group oversight chart and policy/procedures, audits for case management and follows up on execution of corrective actions.
    • Perform internal chart audits and address audit findings with department leadership to ensure the CM team is compliant with all requirements.
    • Provide technical assistance and educational support to contracted medical group care management staff on best practices for fulfilling DHCS contractual requirements pertaining to case management and care coordination.
    • Provide assistance to internal care management staff to resolve contracted medical group-related issues. 
    • Audit and maintain SFHP CM NCQA standards and SFHP policies and procedures.
    • Collaborate with the Care Management Senior Program Manager (CMSPM) on oversight of all Community Based Care Management Entities (CB-CMEs) who are providing the new DHCS Health Homes benefit.
    • Support the CM Children and Family Program Manager in working with contracted/linked partners who serve SFHP’s children to ensure adherence to best practices. These linked/contract partners include, but are not limited to: California Children Services [CCS], Golden Gate Regional Center [GGRC] and the Local Education Agency [LEA]. 



    • A Master’s or Bachelor’s Degree in a related field.
    • 2-3 years of oversight, auditing and monitoring experience.
      • At least 2 years of managed care experience preferred.
      • Experience as a case manager preferred.
    • Proven experience 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 and project management skills especially in handling multiple projects effectively.
    • Clinical quality experience, including experience with case reviews, NCQA, and auditing.
    • Demonstrated critical thinking and problem solving abilities.
    • Ability to produce deliverables that feature exceptional accuracy and precision.
    • Exceptional collaborative abilities including meeting faciliation.
    • Dynamic communication skills, both written and verbal. 




    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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