Quality Review Navigation Specialist

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.

The Quality Review (QR) Navigation Specialist is responsible for critical quality and access improvement activities of San Francisco Health Plan (SFHP), in collaboration with the rest of the Health Services Programs staff and with care providers in provider network. Key partners for this position are SFHP colleagues throughout the organization, our provider network, and SFHP members. The Specialist is responsible for assisting members to navigate the managed care environment and specifically SFHPs network to access needed medical services.

WHAT YOU WILL DO:

Under the direction of the Nurse Supervisor, Quality Review, the QR Navigation Specialist will:

• Advocate for members needs and rights, facilitating communication between members and health care providers to address concerns and improve overall satisfaction. Collaborate with providers and assist members in understanding and navigating the SFHP network and managed care environment, ensuring they receive optimal care.
• Assist members who have filed appeals or grievances to access care by assisting with prior authorizations, securing appointments, obtaining durable medical equipment, medications, transportation and other services as needed to resolve the grievance/appeal.
• Anticipate future member needs to determine whether longer-term support indicated and if so to refer to SFHP or community-based care management and other supportive programs and services.
• Work closely with multidisciplinary teams to address identified issues and promote best practices and foster a culture of continuous improvement. Identify potential interventions to reduce grievances and improve member satisfaction.
• Stay updated on healthcare regulations and accreditation standards, ensuring organizational compliance and recommending adjustments as needed.
• Maintain accurate and detailed records of assessments and activities and outcomes. Assist with development of outcomes tracking measures and report development.
• Some cross-training to other departmental roles is expected as well as performing administrative tasks to support overall departmental objectives.
• Understands and supports the SFHP mission and its overarching business goals and objectives.
• Acts with integrity, honesty and fairness, remaining mindful of the duty of trust SFHP has to its employees, and to its providers, employers and members.
• Accepts and adapts to changes in SFHP policy, practice, procedures quickly and positively and proactively supports colleagues in adapting to changes in the workplace.
• Contributes actively and effectively to team discussions, sharing knowledge and expertise willingly and collaboratively.
• Implements, monitors, utilizes, supports and communicates agreed upon departmental performance competencies metrics.
• Identifies business process improvements that are aligned with and supportive of SFHP business goals and objectives. Provides thoughtful analyses and recommendations.
• Models professional behavior/conduct that remains in concert with the SFHP culture and business values.
• Contributes actively and responsibly to the overall financial viability of the organization and the management of its resources.
• 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:

• HS degree or equivalent work experience. Bachelors in Public Health, social work, Sociology or a similar field preferred.
• Familiarity with San Francisco safety net programs and services is required.
• Social work or health plan appeals and grievances experience strongly preferred.
• At least two years experience in health plan operations, health care clinical quality improvement, direct patient care, or other experience directly related to position duties and knowledge.
• Strong time management, task management, and organization skills across multiple cases.
• Ability to:
  • Work independently and as part of a team.
  • Adjust priorities as needed in a fluid environment.
  • Find and fix problems.
  • Work very efficiently and thoroughly, fill gaps, prevent overlaps.
  • Hold self and others accountable to deadlines.
  • Strong analytical and problem-solving skills preferred in order to communicate recommendations for improvement both within SFHP and in our provider network
  • Customer service and solutions-oriented approach.
  • Strong verbal communication skills for effective work with SFHP members and staff, management, and executives; and with health care providers and practice staff
  • PC literacy required; MS Office skills (Outlook, Word, Excel, PowerPoint).

WHAT WE OFFER:

A competitive and robust compensation package, including:

• Health benefits
  • Medical: Youll 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: Youll 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!