Nurse - Clinical Review

San Mateo County, California
Starting Compensation Range: - Depending on Experience
Jan 08, 2019
Mar 09, 2019
Job Type
Not Specified

The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Clinical Review Nurse to conduct clinical reviews of grievances and appeals filed by members and providers. Clinically evaluates reports of Potential Quality Incidents (PQI), determining the severity of any issues identified and recommending interventions. Identifies areas for quality improvement, both externally and internally, and works with the Grievance and Appeals (G&A) Unit and Medical Directors to implement process improvements.

The essential duties and responsibilities will include the following: 

  • Perform preliminary clinical reviews of all new grievances and appeals to determine whether complaints meet the clinical criteria to be expedited, whether additional medical records are needed, and whether the complaint involves a potential quality of care concern.
  • Conduct and document clinical reviews, including SBARs (situation, background, assessment, and recommendation), for all appeals of medical treatments, procedures, and items. Appropriately utilize relevant clinical guidelines to determine medical necessity and benefit coverage criteria for appeals, including but not limited to Milliman Care Guidelines, Noridian Guidelines, the Medi-Cal Provider Manual, and the applicable HPSM Evidence of Coverage/Member Handbook. Make recommendations to the HPSM Medical Director regarding coverage of medical services.
  • Using case notes, medical records, written responses from providers, and all other relevant documentation, clinically evaluate reports of Potential Quality Incidents (PQI) and Quality of Care (QOC) complaints. Assign PQI and QOC reports a rating of severity, based on established guidelines, and help to identify interventions as needed.
  • Review reports to identify trends in grievances and appeals; make recommendations based on trends identified.
  • Collaborate with internal and external stakeholders to identify and act on opportunities for improvement in the area(s) of utilization management and quality of care.
  • Act as a clinical resource for the G&A Unit in reviewing and resolving complaints.
  • Assist with care coordination for members involved in the grievance or appeals process.
  • Perform other duties as assigned.


Education and Experience: Bachelor’s degree in nursing or a related health services field is a plus. Two (2+) plus years of relevant nursing experience in a managed care, utilization management, disease management, quality improvement, or case management setting.

Knowledge of: Principles and methods of utilization management, including standardized clinical guidelines. Best practices for quality of care. Medi-Cal and Medicare coverage requirements and regulatory guidelines (strongly preferred). Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint. Ability to work in collaboration with a service team where the expectation is to contribute to cases using a dispatcher/case management system.

Ability to: Evaluate medical records and other health care data. Ensure medical appropriateness and effective utilization of health care resources. Work with both clinical and non-clinical staff to resolve member issues. Respond quickly to requests and conduct clinical reviews in an efficient manner. Establish and maintain effective and cooperative working relationships with all levels of HPSM staff as well as plan partners from other programs, agencies, and the general public. Maintain accurate records and confidentiality of sensitive medical information. Assume responsibility and exercise good judgment in making decisions within the scope of authority of the position. Accurately complete tasks within established times and to effectively prioritize multiple tasks and deadlines. Communicate effectively, both verbally and in writing, with individuals from varying cultural and ethnic backgrounds.

Compensation & Benefits

Starting Compensation Range: - Depending on Experience

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage.  Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits.  Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.

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