Nurse Manager, Quality Review

Reporting to the Sr Medical Director, the Nurse Manager, Quality Review provides leadership and oversight of SFHP's quality review functions, ensuring timely and compliant resolution of clinical grievances, appeals, potential quality issues (PQIs), provider dispute resolutions, corrective action plans, and member reimbursement reviews. The Nurse Manager applies clinical judgment to complex and high-value cases, guiding resolution strategies that balance regulatory requirements, organizational standards, and member needs. Serving as a mission-driven leader, you will promote a culture of accountability, high-quality performance, and customer service while supporting the team in achieving departmental priorities and organizational goals.

Please note that while SFHP supports a hybrid work environment, you are required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office.

Salary: $140,000 to $152,000 annual

WHAT YOU WILL DO:

• Provide subject matter expertise and high-level oversight of clinical grievances and appeals, PQIs, provider dispute resolutions, corrective action plans, and member reimbursement reviews.
• Apply clinical judgment to complex and high-value cases, ensuring appropriate resolution strategies and compliance with regulatory standards.
• Review and approve medical necessity determinations for member reimbursement requests.
• Lead investigations of PQIs, ensuring timely resolution and regulatoyr compliance.
• Prepare reports and documentation for monthly, quarterly, and annual requirements.
• Develop, implement, and update departmental policies and procedures to align with state and federal regulations.
• Coordinate audit readiness activities and provide data and documentation for external audits conducted by NCQA, DMHC, DHCS, CMS, and other agencies.
• Manage a team of Qualtiy Review Nurses and a Quality Review Navigation Specialist, providing coaching, mentorship, and performance management.

WHAT YOU WILL BRING:

• 2 to 4 years of related experience in acute care, case management, utilization management, or quality improvement.
• 3+ years in managed care/health plan environment, required.
• 2+ years supervisory/management experience, required.
• An active, unrestricted Registered Nurse (RN) license in California, required.
• BSN required

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.

#LI-Hybrid

(Hybrid remote/in-office)

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