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San Francisco Health Plan (SFHP) is committed to improving the health of our members and their experience of care! As the Manager, Health Services Business Relationships (HSBR) you will have responsibility for leading and developing a diverse team while leveraging technical applications and data systems to support continuous improvement of the business processes that support member outcomes. These systems include the Essette Care Management Software, Verisk HEDIS Software, PreManage Community, First Data Bank’s MedsTracker, and PIPBase (SFHP’s pay-for-performance application). You will serve as an expert in key processes to ensure integration with other SFHP departments. You will also ensure exemplary use of data within the Health Services department, including operational dashboards, SQL reporting, clear report specifications, and integration of data systems.
WHAT YOU WILL DO
Management and Leadership:
- Provide effective leadership and supervision to staff members.
- Support the development of achievable, relevant departmental goals, objectives and metrics, and ensure they are used to continually motivate staff and support high individual and department performance.
- Provide coaching and career development to staff, ensuring high morale and commitment.
- Facilitate effective meetings and provide presentations regarding SFHP’s programs to internal and external stakeholders.
- Serve as Health Services resource with technical and analytic departments to ensure high effectiveness and integration with SFHP’s breadth of information systems.
- Effectively collaborate with SFHP management to ensure success in organization goals.
- Ensure that project management standards are being followed.
- Supports staff with identifying and resolving project barriers.
- Develop and manage budget.
Software/Application Management
- Coordinate with ITS and Operations counterparts to ensure overall functionality of Health Services’ applications, including Essette, PreManage Community, PIPBase, Verscend, and First Data Bank’s MedsTracker.
- Engage business users and stakeholders to identify process improvements and system enhancements.
- Work collaboratively with Health Services and ITS leadership to lead system enhancements and upgrades of business applications.
- Prioritize short-term and long-term goals for applications, ensure inclusion of vendor improvements, system road maps, and integration with other SFHP applications.
- Serve as vendor manager for key applications in Health Services, including RFP process, negotiating small to medium contract terms, contract management, and measuring performance objectives.
- Oversee user acceptance testing to ensure comprehensive application review while minimizing business user effort.
- Ensure adherence to Software Development Life Cycle.
- Facilitate improvements to existing business processes through enhancement or utilization of business applications.
- Ensure adequate training is available for business users.
- Monitor system utilization and recommend improvements as needed.
Reporting and Data Integration
- Coordinate with ITS and Business Intelligence to meet Health Services’ reporting needs.
- Lead thoughtful analyses of Health Services’ operations and promotes the use of data to improve department process.
- Ensures strong collaboration with Population Health, ITS, and BI to identify and resolve data quality issues affecting HEDIS.
- Continually looks for new ways to integrate existing data sources to improve SFHP’s understanding of clinical outcomes.
- Ensure mechanisms are in place that lead to effective and accurate data analysis by Health Services.
WHAT YOU WILL BRING
- Baccalaureate Degree in Healthcare, Information Technology or a related field.
- Masters degree preferred.
- 3+ years of people management/supervisory experience.
- 5+ years of experience in health plan operations, health care business applications, health care information technology systems or other experience directly related to position duties.
- Demonstrated experience completing business requirements, gathering requirements and creating documentation.
- Experience with developing process flow documentation and implementing process re-engineering.
- Strong project management and organization skills across multiple simultaneous projects.
- Budget management expertise.
- Demonstrated ability to work independently and as part of a team.
- Ability to demonstrate and drive team accountability .
- Advanced analytical and problem-solving skills with the ability to formulate and communicate recommendations for improvement.
- Exceptional verbal and written communication skills.
ABOUT US
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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In this organizationally critical role, you will ensure that customer expectations are met (preferably exceeded) and that staff is meeting and exceeding expectations in regards to performance, SLAs, defined IT operational metrics/benchmarks, and standards and processes are followed to provide effective customer service. You will supervise and ensure the efficient operation of the company’s network, applications, servers, system software, databases, and equipment as well as manage the Desktop Systems Support and the Help Desk staff. This role will be focal point for all service delivery services as well as issues.
WHAT YOU WILL DO
- Develop and mature phone/ticket escalation processes to ensure free flowing escalation and information within the organization.
- Manage process for communicating outage/emergency activities to the organization.
- Manage workloads and schedules to optimize service delivery and SLA performance.
- Oversee service requests, incidents, change requests and problems. Manages and coordinates urgent and complicated support issues. Act as escalation point for all requests and incidents.
- Manage and maintain processes for monitoring and responding to system faults, backup failures, etc.
- Liaise with IT management, project teams, and application support groups to coordinate and provide technical resources and support.
- Ensure 24x7x5 incident response, Incident Root Cause Analysis/Post-Mortems, and compliance to ticket SLAs.
- Manage all IT hardware inventory activities and information from acquisition to disposal.
- Oversee management and configuration of the ITSM platform, including service requests, ticketing, change management and problem management.
- Define key operational metrics, develop reporting infrastructure and cadence, set targets and continuously improve. Present monthly operational metrics to IT Leadership. Analyze IT operation metrics and activities for problems and opportunities.
- Liaise with IT management, project teams, and application support groups to coordinate and provide technical resources and support.
- Deploy automation solutions to recurring problems/requests. Support the DevOps tool chain.
- Work with systems administration, network engineering and development teams team to define requirements for monitoring/alerting/logging.
- Support the service catalog, including infrastructure, SaaS, and client devices.
- Partner with security team to enforce security policies and resolve all security remediation activities in a timely manner.
- Work closely with ITS Applications Development, EDI, System Administration, and Project Management teams to oversee handover of new services from delivery teams to IT Operations/Service Desk Management.
- Protect the company by ensuring the integrity of business processes and operations.
WHAT YOU WILL BRING
- A Bachelor’s degree in Computer Sciences or related field.
- Master’s Degree in MIS or Computer Sciences is highly desirable.
- ITIL or ITSM credentials or equivalent experience.
- 7-10+ years of successful information technology work experience.
- Minimum of 5 years of management experience in an IT Operations or Engineering team.
- Demonstrated experience with the Microsoft platform.
- Experience in managing and developing subordinates, promoting teamwork and encouraging innovative ideas.
- Ability to manage multiple projects as the lead and drive cross-functional initiatives
- Strong customer service skills, including strength in written and verbal communication.
- Able to address complex challenges while maintaining composure under high pressure situations.
- Be an organized, creative and a problem-solver.
- Experience with health care organization or health plan preferred.
- Experience with automation, infrastructure as code, configuration management, and continuous delivery technology.
- Demonstrated PC literacy, in particular with MSOffice skills (Outlook, Word, Excel, PowerPoint)
ABOUT SFHP
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 140,000+ 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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Position Summary
The SF City Option Program Manager leads key initiatives and oversees daily operations for SF City Option, an employee health care benefits program for individuals who work in San Francisco. SF City Option, administered by San Francisco Health Plan on behalf of the San Francisco Department of Public Health (SF DPH), provides a way for employers to comply with the San Francisco Health Care Security Ordinance. Since SF City Option launched in 2008, more than 3,500 employers have used SF City Option to make health care benefits available to over 390,000 workers in San Francisco. Learn more about the program at www.sfcityoption.org.
The Program Manager ensures that SF City Option program goals are completed in a high quality, timely, and efficient manner, and that exemplary service is provided to program participants and SF DPH. The ideal candidate for this position must be proactive and highly organized with proven success overseeing a diverse set of operational functions and projects. This position is perfect for the candidate who loves the details, has a passion for making complex things work, can see ways to simplify processes while maintaining program integrity, would rather collaborate than supervise their team members, and strongly believes in the mission of improving health case access as a step toward universal health care for all San Franciscans.
What You’ll Do
- Consistently deliver high quality work products in an environment with frequent workload changes and competing demands.
- Oversee resolution of operational issues as they arise.
- Ensure accurate, useful, meaningful, and timely communications and marketing materials, and oversee the drafting of new and updated communications.
- Lead and manage projects including process improvements and policy changes.
- Collaborate with data analysts to ensure accurate and relevant data reporting to support daily operations, program monitoring, and compliance.
- Effectively use data and metrics to inform program and process design.
- Oversee the review and maintenance of reference documentation, including desktop procedures, process flows, and business rules
You Are
- Service oriented – responsive and collaborative with internal and external stakeholders, balancing programmatic needs with a drive to provide excellent customer service.
- Analytical – enthusiastically tackling operational puzzles and looking for ways to simplify the program and make it more responsive.
- Responsible – leading and taking ownership of the program, knowledge base, and special projects.
You Have
- Bachelor’s degree or equivalent work experience. Master’s degree in business administration, public health, public policy, public administration, or related field preferred.
- Knowledge of local and state health care programs including Covered California, Medi-Cal, the Health Care Security Ordinance, and Healthy San Francisco is preferred.
- Understanding of the basic provisions of the Affordable Care Act and its implementation in California is preferred.
- Knowledge of the basic principles of medical savings accounts is preferred
- Desire to join a team of passionate and dedicated individuals providing innovative health access programs.
- Skill in establishing and maintaining collaborative working relationships with colleagues.
- Prior project management experience on cross-functional projects, including prioritizing tasks and adhering to schedules to meet project deadlines and deliverables.
- Proven ability to handle multiple responsibilities and priorities in a fast-paced environment under limited supervision.
- Ability to formulate logical and objective conclusions from diverse data points and evaluate analyses and reports to support program decision-making.
- Rigorous attention to detail and willingness to assist at all levels in order to ensure on- time and accurate deliverables.
- Strong decision-making skills and judgment, as business lead and subject matter expert, applying policies and procedures with minimal supervision, escalating issues as appropriate. Strong analytical and critical thinking skills.
- Ability to identify potential process improvements and more effective methods of work operations, including identifying alternatives and their implications.
- High level of professionalism communicating through verbal and written forms.
- Strong computer skills, including high proficiency in MS Office (Word, Excel, PowerPoint, Outlook). Competency in Microsoft Visio and SharePoint preferred.
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. San Francisco Health Plan is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 140,000+ 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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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.
ABOUT US
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.
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Are you ready to make an impact on the San Francisco community in a mission-critical, member facing role and help create systemic change?
As a Care Management Community Coordinator (CMCC) you will conduct in-person bio psychosocial assessments, create person-focused holistic care plans, and function as a liaison, coordinating services among multiple providers and community agencies, splitting time at the SFHP office and in the community (at clinics and hospitals, with community-based organizations, and home visits). You will be responsible for managing a wide range of members in variety of different programs and participate in continuous improvement projects that will help build a more effective and efficient service delivery program model.
WHAT YOU WILL DO
- Conduct initial telephone or in-person assessments for members referred for care coordination services or case management, assessing medical history, psychosocial issues, resource needs, and level of function.
- Develop and support the implementation of member-centered, individualized Care Plans.
- Complete home visits, transport and accompany members to medical appointments, and outreach to members in the community including SROs, shelters and homeless encampments.
- In conjunction with the Care Management nurse, support and educate individuals in: chronic condition management; medication management and adherence.
- Coordinate with the nurse to complete the member’s medical assessments and integrate the medical care plan goals.
- Act as a liaison to hospitals, long-term care settings, outpatient providers, home health representatives, and other community agencies.
WHAT YOU WILL BRING
- One or more years of experience in community based outreach.
- Master’s or Bachelor’s Degree in a related field. (Clinical supervision for MSWs may be available for up to 1200 hours.)
- Associate’s degree, Certified Alcohol and Drug Abuse Counselor, or Community Health Worker certificates considered
- Previous case management and outreach experience may be substituted for educational degrees.
- Experience working with people with mental illness, addiction issues, and/or homelessness.
- Experience working with individuals with multiple diagnoses who may have multiple barriers (i.e. mental illness, substance use, access to care, and chronic medical conditions).
- Desire to work with homeless populations in their communities, including encampments, shelters, transitional housing, etc.
- Ability to quickly switch focus between community-based work and office-based work.
- Bi-cultural, bi-lingual language skills strongly preferred. Spanish, Cantonese, Vietnamese or Tagalog a plus.
- Experience with Medi-Cal and/or Department of Health Care Services regulations preferred
- Proficient use of common Microsoft Word applications such as Word, Excel, Outlook and Access
- Working knowledge and use of Trauma Informed, Harm Reduction and Person Centered language and principles.
- Because this position requires member home visits, the incumbent must successfully complete a sex offender registry screen. May be required to pass additional background checks at agency discretion.
ABOUT US
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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Are you ready to help shape the landscape of public healthcare in San Francisco? We're looking for the right individual to bring creative ideas and energy to improve technology in San Francisco’s public health system. Additionally, you'll get to shape one of the first Product Management teams in a public sector organization!
As the Coverage Programs Product Manager, you'll be responsible for the technology products that support Healthy Kids HMO, a public health insurance program for children, as well as Healthy San Francisco, a health access program which aims to provide universal health care to the city. The experienced Product Manager will help us improve access to healthcare and health coverage in San Francisco. You’ll oversee the development of our internal administrative applications and data interchanges, assist in managing technical vendors, and help us determine how to better use technology to support program staff and participants.
What you will do
- Maintain product backlog of enhancements, new features, and bug fixes
- Write detailed user stories and requirements, including wireframes or visual aids as needed
- Work with Healthy Kids and Healthy San Francisco staff to understand program priorities and create product vision and roadmap
- Participate in user research with internal staff and program participants to understand user needs and opportunities
- Lead development teams through Agile release processes
- Create and measure success metrics for product initiatives
- Communicate product initiatives and releases to internal stakeholders across multiple departments
- Conduct user acceptance testing and sign off on releases
- Contribute to vendor management by communicating required changes or bugs with vendor teams
- Conduct market research and make build or buy recommendations for new products
What you will bring
- Bachelor’s degree or equivalent work experience
- Two years of experience as a Product Manager of software products
- Experience in the healthcare or public sector preferred
- Experience with healthcare electronic data interchange formats, such as 834 files a plus
- Basic design skills and ability to communicate new features via sketches, and mockups
- Demonstrated experience in writing clear and detailed product requirements
- Ability to create and build buy-in for product plans and roadmaps
- Outstanding written and verbal communication; ability to break complex topics down for different audiences
- Experience conducting user/design research including interviews, surveys, and usability tests
- Deeply collaborative and an excellent team player
- Ability to build business relationships
- Resilience and comfort with ambiguity
About us:
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. San Francisco Health Plan is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 142,000+ 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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POSITION SUMMARY
The Claims Analyst is accountable for accurate and timely adjudication of claims transactions utilizing edit queues, provider inquiries, refunds, as well as researching and analyzing to determine root causes to streamline the Claims Department’s processes. This position is responsible for recoveries, stop loss reinsurance, reimbursements and processing claims when needed. As part of the team, the analyst must keep current on claim processing procedures and produce a quality and timely work product.
WHAT YOU’LL DO
- Analyze claim issues from identification to resolution. This entails: Identifying claims processing anomalies and offer solutions to address; completing root cause analysis for claims that are not processed accurately; identifying system or process deficiencies and offer suggestions for corrective actions; participating and providing feedback on claims system configuration testing; researching claim errors or inaccurate claim payments and identifying fixes.
- Through analysis and process improvement, assist with accuracy, timely research, and adjudication of claim recoveries and overpayments, including: Coordination of benefits/other health coverage, overpayments (provider refunds) and reimbursement requests, refunds and retro-terminations.
- Lead distinction between complex and non-routine claims processing by utilizing a variety of claims pricing tools for complex manual pricing of claims, interpret complex provider contracts to determine claims payments.
- Represent the claims department as a subject matter expert and provide input to department and cross functional meetings.
- Conform to established standards of performance for quality and timeliness.
- When needed, keep the department’s claim inventory current and clear edit queues by process claims according to verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing.
- Review claims for missing or incomplete information; requesting additional information needed to complete adjudication of claims.
- Review claims for necessity, limitations and exclusions based on claims policies and procedures and document in claims notes to support payments or decisions.
- Determining the level of reimbursement based on established criteria and defined provisions.
- Manage stop loss/reinsurance.
- Determine and process overpayments (provider refunds) and reimbursement requests.
- Ensure that the remit message provides the necessary explanation of payment for the provider
- Reprocess /adjust claims when necessary.
- Assist with service to Providers; handle provider calls promptly and courteously regarding claims status, billing and payment issues, disputes, etc.
- Help with Provider Dispute Resolutions:
- Responding to provider disputes in a timely and accurate manner.
- Researching provider disputes to ensure appropriate resolutions.
- Adjudicating claims that are over-turned thru the PDR process
- Maintaining and updating the Provider Dispute Log.
- Notifying manager of delay reasons that may affect timeliness of processing.
- Work directly with provider groups and Provider Relations to resolve complex claims processing problems/issues.
- Manage special projects within the department such as coordinating audit request
- Maintain current desk level procedures for claims processing
- Create an up-to-date inventory and log and monthly recovery reports where statistics are required for further analysis and monitoring by management personnel.
- Document efforts to collect reimbursement.
- Identifying trends in recoveries that require management intervention
- Recognizing and documenting system issues, and working with manager and ITS to resolve
- Keeping abreast of the changes in Medi-Cal regulations, program policies and current processing procedures.
- Work with the Claims team to ensure consistent and accurate adjudication.
WHAT YOU’LL BRING
- Minimum of 5 years prior work experience in claims operations environment in health care insurance business with 2 years working as an analyst
- High school diploma; college degree preferred
- Demonstrated depth of knowledge and experience in medical claims procedures, processes, governing rules and all aspects of claims adjudication including solid knowledge of CPT/HCPCS, ICD-9 claims coding and medical terminology
- Knowledge of managed care and Medi-Cal reimbursement
- Solid understanding of standard claims processing systems and claims data analysis
- Excellent verbal and written communication skills
- Strong MS Office skills (Word, Excel, PowerPoint)
- Hands-on working knowledge and background using claims processing system(s). QNXT application (V. 4.81 or later) experience preferred
- Detail oriented with problem-solving abilities
- Strong organization, time management and project management skills and multi-tasking abilities
- Excellent qualitative and quantitative abilities
- Ability to handle detailed work, work with varying types of data and maintain confidentiality
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. San Francisco Health Plan 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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POSITION SUMMARY
As a Bilingual Customer Service Representative, you’ll have one of the most important roles in our organization as the face of our Health Plan. If you enjoy working in an exciting, talented & fun team environment where you’ll learn a wealth of knowledge and grow your client relation skills, this is your opportunity. You will naturally thrive on listening, talking with and helping others, be outgoing and committed to improving every member’s call experience and help address any questions and/or issues professionally and efficiently. You are responsible for serving SFHP clients, among them our Health Plan members, prospective members, providers, staff members and the public in general. You will help to provide Health Plan orientation, education, and assistance, including plan benefits, updates, programs, policies, complaints and procedures. Being well spoken, clear and patient with all interactions should accurately describe you.
WHAT YOU'LL DO
- Responds to customer requests, questions, concerns, and complaints in a timely, respectful, caring and competent manner.
- Answers telephone calls promptly and minimizes delays that may lead to abandoned calls.
- Verifies member eligibility, coverage or exclusion of services.
- Assists members in selecting or changing personal doctors or medical groups according to established guidelines.
- Informs and educates customers on Plan policies, procedures and services.
- Promotes the rights and responsibilities of Plan members.
- Provides information, referrals and coordinates member services with community resources for covered and non-covered services.
- Participates in activities that reach out to prospective members and to the communities that the Plan serves.
- Keeps the Customer Service Supervisor and Manager informed of service problems, changes in our contact database, including members, providers, resources, etc.
- Receives customer complaints and works with the Customer Service Supervisor and/or Manager to resolve concerns.
- Provides information to members on preventive and primary care services.
- Compiles and enters electronic data.
- Completes all training programs and certifications as required.
- Assists prospective members with applications for Medi-Cal, Healthy Families, Healthy Workers and other lines of business as needed and according to guidelines.
- Provides coverage of all areas under the responsibility of Customer Service, including front desk and mail services.
- Performs other duties as assigned.
WHAT YOU'LL BRING
- Bilingual fluency/skill in English and Russian, Chinese, Vietnamese, Spanish, or Tagalog is required.
- At least 1-2 years of experience in customer service, call center, or similar.
- Excellent written/oral communication skills with a high degree of professionalism, including discretion in working with confidential information.
- Good knowledge of MS Office and customer management applications.
- Ability to produce accurate, precise and quality work in a dynamic and diverse environment while meeting deadlines.
- Able to work well both as a team and independently.
- Familiar with health care and managed care terminology.
- Prior experience in health care and knowledge of managed care or Medi-Cal preferred.
- College degree is preferred or equivalent work experience.
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. San Francisco Health Plan 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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Are you ready to make an impact to healthcare in San Francisco? At San Francisco Health Plan, by providing superior, affordable health care that emphasizes prevention and promotes healthy living, we strive to improve the quality of life for the people of San Francisco and support the providers who serve them.
The Utilization Management Coordinator is responsible for working with a multi-disciplinary team, serving primarily in an administrative support capacity. The duties of this position include data entry and making telephone calls to providers. The position provides opportunities to work on various projects and authorization requests within utilization management, contingent upon departmental needs. Candidate should have excellent customer service, organization and interpersonal communication skills. The candidate should also take pride in exemplary teamwork and possess a positive attitude.
The work schedule for this position will be:
- Monday, Thursday and Friday - 8:30 AM to 5:00 PM.
- Tuesday and Wednesday - 11:00am to 7:30pm.
- May also require occasional night/weekend overtime.
WHAT YOU’LL DO:
- Research utilization management requests using a variety of resources including SFHP evidence of coverage, policies and procedures, and electronic resources.
- Refer cases to a UM nurse for clinical review and physician provider education.
- Provide administrative and clerical support for utilization management activities through data entry, member tracking, analytical work, and non-clinical research.
- Answer questions and resolve issues promptly from provider, office staff and delegated groups about authorization requests and determinations.
- Ensure the privacy and security of PHI (Protected Health Information) as outlined in SFHP's policies and procedures relating to HIPAA compliance.
- Maintain an accurate census of SFHP members.
- Work closely with providers to obtain accurate information regarding authorization requests.
- Work closely with clinicians to generate Notice of Action (NOA) letters to providers and members.
- Enter required data in various computer programs and databases.
- Maintain databases as needed for reporting requirements.
- Coordinate activities with the other members of the Health Services department and the company as a whole.
- Participate in making member phone calls working from a script, coordinates with members to schedule for their next primary care physician appointment, and identifying when calls need to be referred to a clinician for review.
WHAT YOU’LL BRING:
- Bachelor’s degree in Social Sciences, Life Sciences, Business or a related field preferred or equivalent work experience.
- One year of experience with state and federal insurance programs desired.
- One year of experience in a customer service, call center setting preferred.
- Current California Medical Assistant Certification or California Pharmacy Technician License without restriction or equivalent experience in a health care field with familiarity with medical terminology and concepts a plus.
- Experience with Medi-Cal and/or Department of Health Care Services regulations and standards preferred.
- Experience in an HMO or experience in a managed care setting a plus.
- Detail-oriented with problem-solving abilities.
- Strong organization, time management and project management skills and multi-tasking abilities.
- Ability to handle detailed work, work with varying types of data and maintain confidentiality.
- Ability to work independently and as part of a team.
- Superior written and verbal communication skills.
- Demonstrated proficiency with MS Office (Outlook, Word, Excel, PowerPoint).
ABOUT US:
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. San Francisco Health Plan is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 140,000+ 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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Are you ready to make an impact on the San Francisco community in a mission-critical, member facing role and help create systemic change?
The Care Management Community Coordinator (CMCC) will conduct in-person bio psychosocial assessments, create person-focused holistic care plans, and will function as a liaison, coordinating services among multiple providers and community agencies. This position will be based within the SFHP office but will involve substantial time in the community (at clinics and hospitals, with community-based organizations, and home visits). The CMCC will be responsible for managing members in the Health Homes program, a community-based program for a small subset of Medi-Cal members with complex psychosocial needs and high utilization of acute health services who require coordination at the highest levels. This will require attention to detail and the ability to adhere to workflows and documentation standards. The CMCC is expected to function independently in the field using mobile technology for regular communication with the team and should be comfortable with online clinical documentation.
This is a limited term employee position that will run through 2020.
WHAT YOU WILL DO
- Conduct initial telephone or in-person assessments for members referred for care coordination services or case management, assessing medical history, psychosocial issues, resource needs, and level of function.
- Develop member-centered, individualized Care Plans. Support the Care Management team with implementation of members’ Care Plans:
- Support members in identification of their own strengths and barriers to help them be successful with their Care Plans; respect members’ health choices in the care planning process
- Track access barriers and potential quality concerns, assisting members with grievances and escalating review in coordination with program leadership
- Partner with member in navigating the system of providers and social service agencies
- Support members and caregivers in re-assessment and modification of Care Plan goals
- Help connect members to cultural, community, housing and social resources
- Complete home visits, transport and accompany members to medical appointments, and outreach to members in the community including SROs, shelters and homeless encampments
- Actively participate in SFHP meetings and trainings as needed
- In conjunction with the CM nurse, support and educate individuals in: chronic condition management; medication management and adherence.
- Provide referrals to mental health care; substance use management and treatment; transportation services and other health needs
- Guide members through housing options; complete housing applications and provide advocacy for long term permanent housing for our homeless members
- Initiate and participate in care conferences, ensuring the member’s entire care teams participation
- Coordinate care management activities with the assigned nurse and pharmacy staff, asking for input and consultation as needed
- Coordinate with the nurse to complete the member’s medical assessments and integrate the medical care plan goals
- Complete all required documentation in a timely fashion in accordance with regulations, program standards and workflows
- Maintain privacy and confidentiality practices in accordance with regulations and program standards
- Act as a liaison to hospitals, long-term care settings, outpatient providers, home health representatives, and other community agencies
- Attend and actively participate in regularly scheduled supervision meetings and communicate any concerns to the Supervisor as necessary
- Represent the program to internal and external customers, working closely with member’s PCP and care team
WHAT YOU WILL BRING
- Minimum one year experience in community based outreach
- Bi-cultural, bi-lingual language skills strongly preferred. Spanish, Cantonese, Vietnamese or Tagalog a plus.
- Master’s or Bachelor’s Degree in a related field. Clinical supervision for MSWs may be available for up to 1200 hours.
- Associate’s degree, Certified Alcohol and Drug Abuse Counselor, or Community Health Worker certificates considered
- Previous case management and outreach experience may be substituted for educational degrees
- Experience working with people with mental illness, addiction issues, and/or homelessness
- Experience with Medi-Cal and/or Department of Health Care Services regulations preferred
- Proficient use of common Microsoft Word applications such as Word, Excel, Outlook and Access
- Because this position requires member home visits, the incumbent must successfully complete a sex offender registry screen. May be required to pass additional background checks at agency discretion.
ABOUT US
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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The SFHP Care Management department runs a number of programs to meet the needs of SFHP members. These programs include the Health Homes program, a community-based program for a small subset of Medi-Cal members with complex psychosocial needs and high utilization of acute health services whom require coordination at the highest levels. In this role, you will be responsible for the clinical and administrative oversight of a team of experienced Community Coordinators in addition to acting as a clinical lead for subpopulations served by the plan.
Please note that this position is funded through December, 2020 and as such will have a defined end date.
WHAT YOU WILL DO
- Provide supervision to a Care Management team composed of bachelor’s level and otherwise experienced Community Coordinators.
- Support program strategic development, including the creation of documents, policies and hiring plans.
- Provide supervision, clinical input and oversight to the care management staff within scope of your LCSW/LMFT training.
- Oversee the development of multidisciplinary care plans.
- Regularly audit cases to ensure staff understanding and implementation of program priorities and principles.
- Provider regular performance feedback to the team and resolve day to day performance management issues.
- Work in cohesion with the other clinical supervisors, providing unified direction and oversight to all team members.
- Assist in developing program training curriculum and competencies for program staff.
- Provide orientation for new employees or oversight to staff who will act as a preceptor.
- Working as part of an inter-disciplinary team, add a clinical social work/behavioral health perspective to the management of patients with complex needs.
- Provide timely input and support on any regulatory items such as policies and procedures, audit documents, and contracts to ensure compliance.
- Use your process improvement skills to identify areas for program improvement.
WHAT YOU WILL BRING
- Masters’ degree in Social Work or Psychology.
- Unrestricted clinical LCSW, MFT, or psychologist license.
- 2-3 years of clinical experience.
- 2-5 years of case management experience.
- Excellent oral and written communication skills.
- Demonstrated ability to build professional internal and external relationships.
- Proficiency in mentoring for individual and team growth.
- Experience with complex populations (homelessness, mental illness, substance use).
- Bilingual in Spanish or Cantonese preferred but not required.
- The ability to successfully complete a sex offender registry background screen (position may require home visits).
- Demonstrated proficiency MS Office (Outlook, Word, Excel, PowerPoint).
- Working knowledge and use of Trauma Informed language and principles is desired.
ABOUT US
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 under-served 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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Are you passionate about program management and behavioral health? Bring that passion to San Francisco Health Plan and help us grow our newest member offering!
As the Program Manager of Behavioral Health you will be responsible for managing the mental health programs at the San Francisco Health Plan. This includes:
- Non-specialty mental health services for Medi-Cal, which are currently delegated to our partner, Beacon Health Options
- Behavioral health services provided by the San Francisco Department of Public Health Community Behavioral Health Services (CBHS) for Healthy Kids and Healthy Workers
As these services are delegated to external partners, a large component of the role involves coordination with, and oversight of vendor services, in partnership with multiple SFHP departments. You will function as the primary clinical liaison to both vendors and work collaboratively with SFHP partners to ensure Beacon and CBHS successfully meet the goals established by SFHP and the regulatory requirements promulgated by the Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and the National Committee for Quality Assurance (NCQA).
WHAT YOU WILL DO
- Act as the clinical point of contact, in collaboration with the Chief Medical Officer (CMO), and for the Beacon Contract Manager to ensure:
- Contract goals are created, monitored and successfully completed.
- Delegated quality, utilization management and credentialing performance meets aforementioned requirements.
- Effective collaboration with the Beacon management team.
- Collaborate with SFHPs Provider Relations Network Manager to set agendas and ensure follow-up to the quarterly/monthly Joint Administrative Meetings (JAMs) with behavioral health providers.
- Partner with the CMO and other Health Services Directors to effectively integrate SFHP’s behavioral health benefit into SFHP’s Care Management program.
- Collaborate with Beacon and SFHP Provider Network Operations to ensure effective, accessible behavioral health programs are in place.
- Partner with Care Management’s (CM) Strategic Partnerships Program Manager to build relationships with and integrations for substance use and housing providers.
- Coordinate with the CM Children and Family Program Manager to provide oversight and triage issues relating with member’s connection to Behavioral Health Therapy (BHT).
- Actively communicate with the CM program management (PM) staff, ensuring standard documentation and adherence to PM best practices.
- In collaboration with SFHP's Grievance Review team, ensures behavioral health complaints and grievances are adjudicated appropriately.
- Collaborate with SFHP’s Finance and Provider Relations staff and Beacon to analyze and ensure the SFHP behavioral health program meets overall financial targets.
- Actively contribute to behavioral health audit preparation (DHCS, DMHC, and NCQA audits).
- Oversee and ensure that on-site Beacon staff are effective partners with SFHP staff.
- Effectively represent SFHP in meetings with key external constituents/stakeholders.
WHAT YOU WILL BRING
- Masters’ degree in Social Work or Psychology
- Must be a California licensed mental health or substance abuse clinician.
- Minimum of 3 years program management experience.
- Demonstrated project management expertise.
- Superior written and verbal communication skills.
- Ability to collaborate effectively on cross-functional teams.
- Expert critical thinker and problem solver who can effectively communicate solutions to a broad audience.
- Experience with the audit process of clinical activities preferred.
- Experience working in quality management/improvement, preferred.
- Knowledge of NCQA standards preferred.
ABOUT US
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.