San Francisco Health Plan is looking for a Prior Authorization Nurse I, a registered nurse who is passionate about making a difference in the lives of individual members and improving our system of healthcare in San Francisco.

Reporting to the UM Nurse Manager of Prior Authorization, the Prior Authorization Nurse I is a universal healthcare advocate who is focuses on high-quality care for members, has a good mix of nursing knowledge and business experience, works autonomously and makes decisions on behalf of members. You are proficient in database navigation and want to work in an office environment.

Position is open to remote, however, the applicant must possess an active, unrestricted California RN license.

WHAT YOU WILL DO:

• Utilization management: review of 15-30 prior and retrospective authorization requests per day.
• Coordination with Medical Directors to ensure members receive appropriate services within their medical group and network as medically appropriate.
• Coordinate the preauthorization process for medical group services including second opinions, independent medical review, and experimental and investigational services.
• Escalate issues to manager.
• Coordinate care for members.
• Collaboration with team members on cross-departmental improvement efforts: quality improvement projects, member satisfaction improvement, and decreasing avoidable ER use.

WHAT YOU WILL BRING:

• Current Registered Nurse license in the State of California without restriction.
• Mix of nursing and general business experience.
• Broad spectrum experience in care support settings, acute ambulatory, or rehabilitation care setting preferred.
• Prior experience in case management, resource management or utilization review preferred.
• Experience with Medi-Cal or Department of Health Care Service regulations and standards preferred.
• Ability to assess needs from member files, research to uncover gaps, and knowledge and confidence to make authorization determinations and recommendations and referrals to other programs

BENEFITS:

• Retirement: CalPERS Pension Plan, CalPERS 457 Supplemental Income Plan and a 401(a) defined benefit plan.
• Medical Plan: Choice of Aetna HMO, Sutter/Aetna OAMC POS, or Kaiser HMO (100% premium paid for HMO employee-only coverage)
• Dental Plan: The Principal EPO dental coverage with option to cover orthodontia.
• Time Off: 23 days of Paid Time Off and 12 observed company holidays.
• Professional development: Opportunities for tuition reimbursement, professional license/membership

Candidates will be required to show proof of up-to-date vaccination against COVID-19 as defined by the San Francisco Department of Public Health upon beginning employment. Reasonable accommodations will be considered on a case-by-case basis for exemptions to this requirement subject to the applicable law[s].

ABOUT SFHP:

Established in 1994, 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 170,000+ 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.