The Clinical Quality and Enhanced Care Management/Community Supports Oversight Nurse is responsible for establishing and strengthening relationships with ECM and Community Supports providers to ensure quality of care and regulatory compliance standards are met. They will partner closely with the State Programs Team, Provider Network Operations and Compliance departments to establish clinical oversight review standards for ECM/CS providers, review care plans and escalate concerns, as needed. The position will be responsible for ensuring providers meet DHCS regulations, SFHP policies and procedures. They will also act as the Clinical liaison between SFHP and ECM and Community Supports providers and assist providers with complex members, as needed. They will work collaboratively with all levels and departments of San Francisco Health Plan and represent the State Programs Team.

This is a temporary position with the possibility of converting to a full-time employee.

Salary: $60 to $65 per hour

WHAT YOU WILL DO

• Acts as a liaison between SFHP State Programs team, ECM/CS providers and hospitals
• Develops and implements a clinical oversight process for all ECM/CS providers.
• Contributes to the development and implementation of clinical process standards and requirements for ECM and CS services, as applicable.
• Communicates effectively to provide assistance to ECM/CS providers to resolve member issues and ensures provider inquiries are properly and effectively handled, and promptly followed up on.
• Utilizes ECM/CS data to prepare and track program performance, utilization and quality review reports for providers and SFHP, and follows up on corrective actions.
• Conducts regular review of provider care plans, and reports, and provides feedback as needed to ECM and CS providers.
• In partnership with SFHP’s Compliance Team, participates in the clinical review of SFHP’s internal audits on a quarterly basis and assists in addressing any findings.
• Conducts ad hoc trainings for ECM/CS providers on SFHP policies.
• Participates in DHCS and DMHC audits.
• Participates in monthly ECM/CS provider meetings, hospital meetings and Joint Administrative Meetings, as needed.
• Actively contributes toward ECM/CS program goals, process improvements, and continuously improves the managed care processes.
• Works collaboratively with all functional departments within SFH.P
• Plans and organizes work to ensure operational efficiency and effectiveness of the department.
• Demonstrates expertise in researching and trouble-shooting complex clinical situations and policy issues.
• Participates in the development and review of policies and procedures.

WHAT YOU WILL BRING

• A current State of California RN license to practice without restriction
• At least 2 years of clinical experience required
• At least 2 years of managed care experience preferred
• At least 2 years of auditing or clinical oversight experience preferred
• At least 2 years of case management experience required
• Knowledge of state and federal insurance programs preferred
• Experience with Medi-Cal, and/or Department of Health Care Services regulations and standards, required
• Proven organizational skills and project management skills especially in handling multiple projects effectively
• Clinical quality experience, including experience with case reviews
• Experience offering training or mentorship to staff new in the field of case management, including, but not limited to, providing education on best practices, strategies for client engagement, care planning, and addressing clinical safety issues.
• PC literacy; MSOffice skills (Outlook, Word, Excel, PowerPoint)