Reporting to the Senior Director, Health Services Clinical Operations, the Director, Clinical Operations provides strategic and operational leadership. This leadership is for SFHP's Utilization Management (UM) program, ensuring members receive medically necessary, and cost-effective care. You will oversee all UM activities. These activities include prior authorization, concurrent review, discharge planning, and delegated oversight. Additionally, ...
Reporting to the Director of Clinical Operations, the Nurse Manager, Prior Authorizations, provides clinical and operational leadership to the Prior Authorizations (PA) team within the Utilization Management (UM) function. You will manage a team of registered nurses and clinical staff responsible for prior authorization reviews, ensuring determinations are on time, clinically appropriate, and compliant with Medi-Cal, DHCS, and SFHP standards. Ple...
Reporting to the Director of Clinical Operations, the Nurse Manager, Prior Authorizations, provides clinical and operational leadership to the Prior Authorizations (PA) team within the Utilization Management (UM) function. You will manage a team of registered nurses and clinical staff responsible for prior authorization reviews, ensuring determinations are on time, clinically appropriate, and compliant with Medi-Cal, DHCS, and SFHP standards. Ple...
Reporting to the Chief Executive Officer (CEO) of San Francisco Health Plan (SFHP), the Chief Financial Officer ensures the financial viability and manages the financial affairs of SFHP in the follwing: sound business practices. all applicable government regulatory and grantor/funder requirements. SFHP internal controls and policies. and the strategic and annual business goals and objectives of the organization. As a key member of the SFHP Execut...
San Francisco Health Plan is committed to providing high-quality care for low-income San Franciscans and supporting the provider safety net. We leverage our resources to support the triple aim: improved population health, improved quality of care, and improved affordability. The Medical Director is the Plan's primary UM physician conducting concurrent and prior authorization case reviews. You will be the health plan physician lead on the Health H...
Reporting to the Sr Medical Director, the Appeals & Quality Review Nurse Manager, 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 strate...
Reporting to the Director, Compliance and Oversight, the Health Plan Audit Analyst supports the San Francisco Health Plan (SFHP) Compliance Program through audit and monitoring activities. You will audit and monitor external provider and vendor entities and internal department processes. You will also develop audit tools, audit reports, and criteria metrics and also communicate with internal and external stakeholders on the status of auditing act...
Reporting to Manager, Clinical Operations Administration, the Clinical Quality and Oversight Nurse is responsible for ensuring utilization management (UM) activities comply with regulatory and accreditation requirements (CMS, DHCS, DMHC, NCQA). You will provide oversight of both internal UM processes and delegated entities to ensure consistent application of clinical criteria, adherence to regulatory and contractual standards, and delivery of hig...
Reporting to the Sr Manager, Medicare Sales, the Medicare Telesales Representative is responsible for enrolling members into San Francisco Health Plan's new Dual Special Needs Plan (D-SNP). You will connect with the underserved, Medicare-eligible individuals, with an understanding of their comprehensive Medicare and Medi-Cal benefits, you will review their health coverage and explain how the SFHP Care Plus DNSP plan can meet their unique health a...
Reporting to the Clinical Supervisor, Care Management, the Care Management Nurse provides clinical assessment, nursing interventions, and coordinated care planning for SFHP members with complex and chronic health needs in multiple programs. Working in close partnership with Care Management Community Coordinators (CMCCs), the nurse evaluates medical risks and conducts nursing assessments. The nurse also delivers chronic-condition evaluation, recon...
Reporting to the Clinical Supervisor, Care Management, the Care Management Nurse provides clinical assessment, nursing interventions, and coordinated care planning for SFHP members with complex and chronic health needs in multiple programs. Working in close partnership with Care Management Community Coordinators (CMCCs), the nurse evaluates medical risks and conducts nursing assessments. The nurse also delivers chronic-condition evaluation, recon...
