Clinical Quality and Oversight Nurse
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![]() United States, California, San Francisco | |
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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 high-quality, member-centered care. You will partner with the Compliance and Provider Network Management departments to complete all UM oversight audits and are responsible for establishing and strengthening relationships with delegated entities to ensure tactical alignments and regulatory compliance are met Please note that while SFHP offers a hybrid work environment, this position is not required to meet the minimum in-office requirement of 4x/month; however, you must be flexible and available to work onsite as determined by the manager. Salary: $55 - $65 per hour WHAT YOU WILL DO:
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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) Please see job description PI278523534 |