Reporting to the Director, Care Management, the Enhanced Care Management & Community Supports Oversight Nurse establishes and strengthens relationships with Enhanced Care Management (ECM) and Community Supports (CS) providers to ensure quality of care and regulatory compliance standards are met. You will partner with the Care Management Team, Provider Network Operations and Compliance departments to establish clinical oversight review standards for ECM/CS providers, review care plans and escalate concerns. You will ensure providers meet DHCS regulations, SFHP policies and procedures. You will be the Clinical liaison between SFHP and ECM and Community Supports providers and assist providers with complex members.
Salary: $52.56 per hour to $64.11 per hour
WHAT YOU WILL DO
- Be a liaison between SFHP State Programs team, ECM/CS providers and hospitals.
- Develop and implement a clinical oversight process for all ECM/CS providers.
- Contribute to the development and implementation of clinical process standards and requirements for ECM and CS services, as applicable.
- Provide assistance to ECM/CS providers to resolve member issues and ensure provider inquiries are handled and promptly followed up on.
- Utilize ECM/CS data to prepare and track program performance, utilization and quality review reports for providers and SFHP, and follows up on corrective actions.
- Conduct regular review of provider care plans, and reports, and provide feedback to ECM and CS providers.
- In partnership with SFHP's Compliance Team, participates in the clinical review of ECM and CS provider audits on a quarterly basis and assist in addressing any findings.
- Conduct ad hoc trainings for ECM/CS providers on SFHP policies.
- Participate in regulatory audits, including DHCS and DMHC audits.
WHAT YOU WILL BRING
- A current State of California RN or LVN license to practice without restriction.
- 2 years of clinical experience required.
- 2 years of case management experience required.
- 2 years of managed care experience, auditing or clinical oversight experience in the state or federal insurance programs preferred.
WHAT WE OFFER
- Health Benefits
- Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
- Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
- Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
- Retirement - Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
- Time off - 23 days of Paid Time Off (PTO) and 13 paid holidays.
- Professional development - Opportunities for tuition reimbursement, professional license/membership.
ABOUT SFHP
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 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.
San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
San Francisco Health Plan is an E-Verify participating employer.
Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.
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