Utilization Review Nurse Salary in San Francisco, CA

San Francisco Health PlanAs a member of the Population Health and Quality department, the Quality Review Nurse (QRN) will support key clinical quality initiatives at San Francisco Health Plan (SFHP). The QRN is part of SFHP Health Services department which includes Population Health and Quality activities of the Plan. The QRN supports and leads clinical review activities within SFHP's Quality department by providing clinical input and oversight for the following quality areas. Grievance and Appeals Potential Quality Issues, including Provider Preventable Conditions Clinical Quality InitiativesThe QRN works closely with the Grievance and Appeals team and the SFHP Medical Director to ensure that clinical quality concerns are addressed in all grievances and appeals. As a member of SFHP's the Grievance Review Committee, the QRN supports the Grievance and Appeals team in ensuring that clinical concerns are addressed as part of grievance investigations.Reporting to the QRN Manager and under the guidance of SFHP Medical Director, the QRN will support and manage the review and resolution of Potential Quality Issues (PQIs) and other clinical quality related initiatives. In addition, the QRN will support initiatives within the Quality Improvement Plan including those related to Healthcare Effectiveness Data and Information Set (HEDIS), CAHPS (Consumer Assessment of Healthcare Providers and Systems) metrics and other California Department of Healthcare Services (DHCS) metric performance.This role is highly cross-functional and collaborative, partnering closely with teams in both Health Services Operations and Health Services Programs departments as well as other areas of SFHP, especially Compliance and Customer Service.Salary range: $52.56 to $64.25 per hourWHAT YOU WILL DO Support Quality Process: Support process improvement activities, and compiling in relation to department and quality metrics Review clinical quality processes and identifies workflow enhancements. Participates in the Quality Improvement Committee and UM Committee as appropriate. Document clinical reviews in care management system/tracking system. Actively contribute toward program and process improvements and goals; continuously improve the managed care process. Participate in DHCS, DMHC, and NCQA audits. Grievance and Appeals Review incoming grievance and appeals for clinical quality concerns and expedited status. Document clinical reviews and provides clinical support and guidance to the Grievance and Appeals Team. Participate in case conferences. Provide clinical information and assessment of care during Grievance Review Committee (GRC). . Potential Quality Issues Identify, investigate and document potential quality issues (PQIs). Under the guidance of SFHP Medical Director, initiate and complete PQI investigations, including development of necessary clinical quality follow up and corrective action plans. Support identification and reporting of Provider Preventable Conditions (PPC). Clinical Quality Initiatives Provide clinical support to all quality activities. Assist with the operation of San Francisco Health Plan's quality improvement program. Assist in data collection and support reporting in relation to quality metricsWHAT YOU WILL BRING Registered Nurse license in the State of California without restriction, or LVN with 3 or more years health plan experience A current license to practice without restriction. A Bachelor's degree in Nursing desired At least 2 years of managed care experience. Knowledge/experience with San Francisco safety net programs and providers. Competency in building relationships with providers. Knowledge of state and federal insurance programs. Experience with Medi-Cal and/or Department of Health Care Services (DHCS) regulations and standards, required. Proven organizational skills and project management skills especially in handling multiple projects effectively. Clinical quality experience. NCQA and auditing experience preferred Knowledge and experience with health care quality models such as PDSA preferred.WHAT WE OFFER: A competitive and robust compensation package, including: Health benefits Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California. Employee-only coverage in the HMO plans is currently available at no cost and dependent coverage is 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. An opportunity to work in a vibrant atmosphere with the most amazingly talented people who are shaping the future of healthcare! The chance to make a difference in the lives of many San Francisco residents!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. SFHP was designed by and for the residents it serves and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.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. PI239122117

Careers that Change Lives Bring your talents to an industry leader in medical technology and healthcare solutions - we're a market leader and growing every day. You can be proud to sell medical technologies that are rooted in our long history of mission-driven innovation. Our expanding portfolio delivers measurable clinical and economic value - and opens doors. You will be empowered to shape your own career. We support your growth with the training, mentorship, and guidance you need to own your future success. Together, we can transform healthcare.Join us for a career in sales that changes lives.The Ear, Nose, and Throat Operating Unit is a global leader and trusted partner for innovative ENT solutions that improve patient access, outcomes, and customer satisfaction. We partner with the ENT community to understand the needs of customers and patients, delivering solutions that improve lives as we embody a culture of accountability and trust. Over the past 20 years, we have become the global market leader in three key segments - image-guided surgery, intraoperative nerve monitoring, and powered surgical instruments. We continue to launch valuable ENT solutions in these areas as well as tissue health and balloon sinus dilation.Click here to learn more about products.The Market Development Representative is responsible for case support and selling activities. This role reports to the local district manager but has a dotted line to 1-3 area sales managers where accounts have multiple team members. The majority of time is spent maintaining established customer relationships and expanding utilization of current and adjacent products in the ENT portfolio.Responsibilities may include the following and other duties may be assigned. Responsible for developing, building, and strengthening long-term relationships with stakeholders including surgeons, nurses, administrators and key opinion leaders. Responsible for pursuing leads, assessing needs and providing product support and services to maximize the benefits derived from Medtronic's ENT products and/or services. Provides technical support during cases and informs the clinician of patient treatment options. Promotes education of the company's products and/or services. Conducts and/or evaluates market research including customers and competitors' activities. Develops and/or implements market development plans/strategies and changes as needed. Assesses customer needs and feedback regarding new products and/or modifications to existing products and communicates to internal stakeholders including R&D, Operations and Marketing. Establishes effective relationships and collaborates with other departments (Marketing, Finance, HR, Sales Training, etc.) to address key business issues and opportunities. The above statements are intended to describe the general nature and level of work being performed by employees assigned to this position, but they are not an exhaustive list of all the required responsibilities and skills of this position. We seek out and hire a diverse workforce at every level: We need fresh ideas and inclusive insights to continue to be an innovative industry leader -that's why we make it a point to seek out, attract and develop employees who are patient-centric, passionate, and who represent the same wide variety of life experiences as our patients.To learn more about Inclusion & Diversity at Medtronic Click Here Must Have: Minimum Requirements To be considered for this role, please ensure these minimum requirements are evident on your resume. A Bachelor's degree Nice to Have 2 Years of sales or clinical experience Operating Room Experience Relationships within the ENT space Preference will be given to local qualified candidates and candidates with Medtronic experience. About Medtronic Together, we can change healthcare worldwide. At Medtronic, we push the limits of what technology, therapies and services can do to help alleviate pain, restore health and extend life. We challenge ourselves and each other to make tomorrow better than yesterday. It is what makes this an exciting and rewarding place to be.We want to accelerate and advance our ability to create meaningful innovations - but we will only succeed with the right people on our team. Let's work together to address universal healthcare needs and improve patients' lives. Help us shape the future. Physical Job Requirements Required to function using healthcare universal precautions to minimize exposure to infectious disease and radiation. Ability to serve as the primary resource for scheduled and unscheduled clinical events, periodically required to work weekends, evenings and nights and may be required to engage in overnight travel within own district or neighboring districts. Ability to work efficiently and autonomously with little direction when outside of clinical events. Ability to attend national meetings, district meetings and other training as requested. Ability to wear a 7-9 lbs protective lead apron for extended periods of time in the operating room. Ability to lift up to 40 pounds. Ability to sitting, standing, and/or walking for 8+ hours per day. Ability to bend/stoop, squat and balance frequently. • Specific vision abilities required by this job include close vision, distance vision, depth perception, and ability to adjust focus in relation to travel and operating a personal computer.Must have a valid driver's license and active vehicle insurance policy. In addition, your driving record will be reviewed and will be considered as part of your application. Must be able to drive approximately 50% of the time within assigned territory and may require overnight travel.The physical demands described within the Day in the Life section of this job description are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.A commitment to our employees lives at the core of our values. We recognize their contributions. They share in the success they help to create. We offer a wide range of benefits, resources, and competitive compensation plans designed to support you at every career and life stage. Learn more about our benefits here .In addition to Base Salary, this position is eligible for a Sales Incentive Plan (SIP), which provides the opportunity to earn significant incentive compensation for achieving or exceeding your goals. Learn more about total rewards here .The base salary range is applicable across the United States, excluding Puerto Rico and specific locations in California. The offered rate complies with federal and local regulations and may vary based on factors such as experience, certification/education, market conditions, and location. Compensation and benefits information pertains solely to candidates hired within the United States (local market compensation and benefits will apply for others).

San Francisco Health PlanThe Concurrent Review Coordinator is responsible for working with a multi-disciplinary team, serving primarily in an administrative support capacity. Primary focuses of this position include data collection, authorization management, correspondence compliance, discharge planning, and overall support of the CCR/CT team's functions. You also serves as communication liaison with members, clinics, hospitals, and community partners to support care transitions efforts from inpatient to outpatient settings. The position provides opportunities to work on various projects and authorization requests within utilization management and clinical operations, contingent upon departmental needs.You should have excellent customer service, organization, and interpersonal communication skills. You should also take pride in exemplary teamwork and possess a positive attitude. Salary: $25.58 - $32.25/hour WHAT YOU WILL DO Research utilization management requests using a variety of resources including SFHP evidence of coverage, policies and procedures, and electronic resources. Compile data for utilization management review and submit the data to the Concurrent Review nurse team for clinical decision-making. Maintain ongoing tracking and appropriate documentation to facilitate the determination process within the regulatory timeframes for standard and urgent authorization requests. Assist in discharge planning efforts for members requiring post discharge follow-up care through telephonic coordination with primary care providers. Provide administrative and clerical support for utilization management activities. Communicate effectively and timely to answer questions and resolve issues pertaining to providers, office staff, and delegated groups about authorization requests and determinations. Respond to calls, emails, and other inquiries regarding the status of outstanding clinical requests and utilization management processes Ensure the privacy and security of PHI (Protected Health Information) as outlined in SFHP's policies and procedures relating to HIPAA compliance. Maintain an accurate census of SFHP members. Work closely with providers to obtain accurate information regarding authorization requests. Ensure correspondence distribution compliance by working closely with designated clinicians to generate Notice of Action (NOA) letters for the requesting providers and members Foster an environment that solicits and enlists diverse and inclusive perspectives and approaches to better serve our staff, our members and our providers. WHAT YOU WILL BRING One year of experience with state and federal insurance programs. One year of experience in customer service, call center setting. A bachelor's degree in health, Social or Life Sciences, Business, or a related field, preferred, or equivalent work experience; Current California Medical Assistant Certification or California Pharmacy Technician License without restriction or equivalent experience in a health care field with familiarity with medical terminology and concepts, preferred. Experience with Medi-Cal and/or Department of Health Care Services regulations and standards preferred. Experience in an HMO or experience in a managed care setting preferred. WHAT WE OFFERA competitive and robust compensation package, including: Health benefits Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California. Employee-only coverage in the HMO plans is currently available at no cost and dependent coverage is 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. An opportunity to work in a vibrant atmosphere with the most amazingly talented people who are shaping the future of healthcare! The opportunity to make a difference in the lives of many San Francisco residents! San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports and respects all individuals and in which our 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. PI239373651

San Francisco Health PlanThe 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 hourWHAT 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) PI239707545