San Francisco Health Plan

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 supports a hybrid work environment, the Clinical Quality and Oversight Nurse, is not required to meet the minimum in-office requirement of 4x/month but is required to attend company meetings and other...

Reporting to the Director, Regulatory Affairs, the NCQA Program Manager is an experienced healthcare professional who manages and leads activities associated with SFHP's NCQA Accreditation. These activities include ongoing monitoring and analysis of plan performance against the NCQA standards. Additionally, the Program Manager coordinates all NCQA-related activities across the organization to maintain and prepare for ongoing NCQA accreditation and future categories of NCQA accreditation. Position activities involve frequent daily interface with SFHP internal departments to support NCQA accreditation standards. Serve as the departmental contact for all matters related to NCQA accreditation. You must be extremely professional and organized. You must demonstrate high standards of integrity. Additionally, they should enjoy interacting with people at all levels. They thrive in a fast-paced environment. You must be able to motivate others to excel and persist as a team. Furthermore,...

Reporting to the Operations Officer, the Director, Claims, provides strategic management. This involves collaboratively leading the ongoing operations of the Claims Department at SFHP. The Director's responsibilities also include ensuring financial integrity and exemplary service, and achieving established goals and objectives. You will also maintain internal communications to promote SFHP's mission. They support SFHP's core purpose and work to maintain a team environment. In this environment, staff can be effective, satisfied, and provide quality service to all customers, both internal and external. 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: $150,000 - $183,000 per year WHAT YOU WILL DO: Plan and manage Claims and Quality Assurance. Manage, coach, and inform the department managers and...