In this critical position that directly supports one of San Francisco Health Plan's (SFHP) key organizational objectives, the Nurse Specialist will support and collaborate with both the Director of Provider Network Operations and the Senior Nurse Specialist to ensure SFHP is compliant with all DHCS (Department of Health Care Services) requirements regarding facility site, medical record (FSR), interim monitoring, and FSR-C (provider accessibility) reviews. In this role, you will support development, execution and oversight of the FSR and FSR-C program.
WHAT YOU WILL DO
- Conduct FSR (Facility Site Review Survey and Medical Record Review) and FSR-C (Provider Accessibility) reviews.
- Ensure SFHP is in compliance with DHCS requirements for all components of FSR and FSR-C.
- Manage and maintain the FSR and FSR-C work plans, schedule, and external Collaboration Site; enter results into provider database (HDS).
- Issue Corrective Action Plans (CAP) as needed and provide outreach, education and follow- up to ensure CAP implementation.
- Manage the FSR and FSR-C schedule upload completed reviews into the SFHP Collaboration Site.
- Ensure that delegated groups submit completed FSR and FSR-C documents per stated guidelines and requirements.
- Review medical group’s submission for timeliness and completeness of the review.
- Report provider quality issues to the Chief Medical Officer, or clinician designee and present cases to Physician Advisory Committee as needed, providing recommendations and implementing follow-up actions.
- Report FSR scores to the DHCS biannually using the agency’s database.
- Update and maintain provider resources needed to comply with DHCS requirements for FSR and FSR-C.
- Collaborate with Senior Nurse Specialist to strategically evaluate and improve internal FSR processes.
- Train and certify nurse reviewers as necessary.
- Attend biannual DHCS Site Review Workgroup (SWRG) meetings.
- Maintain Anthem Blue Cross (ABC)/SFHP MOU; participate in quarterly ABC/SFHP MOU meetings.
- Update SFHP Policy and Procedures for FSR and FSR-C, Network Operations Manual, Summary of Key Information, QI Evaluation, and other required documents and reports as needed.
- Participate in DHCS and DMHC audits of the Health Plan and follow up with providers on any corrective action plans (CAP) issued by the agencies.
- Collaborate with CHDP and other county agencies as needed to ensure SFHP participation in and contribution to local health initiatives and programs.
WHAT YOU WILL BRING
- BA/BS degree required; master’s/graduate degree preferred.
- Nurse or physician with an unrestricted California license.
- Minimum 3 years of clinical experience.
- Minimum 3 years of experience in quality improvement or related clinical activity, preferred.
- Proficient with health information technology systems (QNXT, Essette, or similar)
- Ability to clearly and concisely communicate and present issues, concepts, reports, findings and technical information.
- Demonstrated ability to identify problems and develop comprehensive solutions.
- Superior collaboration and relationship building skills.
- Act as an ambassador of SFHP to internal and external stakeholders.
- Demonstrated proficiency in MS Office (Outlook, Word, Excel, SharePoint, and PowerPoint) and web based tools.
Established in 1997, San Francisco Health Plan (SFHP) is 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.