2322 Nurse Manager - Quality Management

Recruitment #CBT-2322-109487


2322 Nurse Manager – Quality Management


Applicants are encouraged to apply immediately as this recruitment may close at any time but not earlier than April 23, 2021.


The San Francisco Department of Public Health (DPH) is accepting applications in Class 2322 Nursing Supervisor – Quality Management.


Positions may be located throughout the San Francisco Department of Public Health, including, but not limited to: Laguna Honda Hospital and Rehabilitation Center (LHH) and Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG).


Current vacancy in Risk Management at Laguna Honda Hospital and Rehabilitation Center, please see details below.


General Job Description:
Under the general supervision of the Nursing Administrative Leadership, the 2322 Nurse Manager (Quality Management) works in one of four functional areas to include: Utilization Management, Risk Management, Regulatory Affairs, or Patient Safety.


Essential Duties:
The Nurse Manager– Quality Management performs the following essential job functions:

Regulatory Affairs:

·                  Serves as an expert for compliance with the Health Insurance Portability and Accountability Act (HIPAA), State Laws pertaining to Privacy and Security, Joint Commission standards, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation and California Title 22 requirements and ensures Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) is in compliance with all applicable accreditation and licensing requirements;

·                  Demonstrates and maintains knowledge of both DPH and hospital policies and procedures to ensure regulatory compliance;

·                  Provides education and training for all staff through workshops, orientation and training, consultation and needs assessments;

·                  Furthers the goals of the hospital through participation in the management team and the strategic planning process;

·                  Maintains accurate records, prepares written reports and provides statistical analysis;

·                  Conducts chart reviews, investigations and provides critical analysis of adverse outcomes;

·                  Strategically prioritizes large workloads in a thorough and organized manner; AND

·                  Represents ZSFG with all accreditation and licensing bodies.


Utilization Management:

·                  Develops, implements and monitors Utilization Management objectives and activities focusing on assisting patient flow;

·                  Collects and reviews statistics and other data and reports to define/establish baseline service needs as well as identify trends, evaluate workload, and other factors which may impact the delivery of Utilization Management;

·                  Coordinates Utilization Reviews with both internal and external stakeholders utilizing InterQual Criteria;

·                  Promotes the utilization of resources through planning, managing and evaluating patient care;

·                  Identifies department needs related to space and other issues;

·                  Provides reports to administration and other appropriate forums to assist in overall hospital and clinic planning efforts;

·                  Provides the necessary vision and leadership to effectively motivate and direct the Utilization Management Department in developing and achieving goals and objectives that are congruent with the values, mission and strategic plan of Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG), San Francisco Health Network, and the San Francisco Department of Public Health;

·                  Monitors and evaluates staff scheduling practices to ensure that sufficient qualified staff are available to meet service demand and assignments are made appropriately and equitably;

·                  Maintains, promotes, and enforces a "Customer Service" philosophy; 

·                  Considers factors related to safety, cost, and effectiveness when managing care delivery systems; 

·                  Keeps abreast of current professional standards and practices and incorporated changes into departmental practice and programs when appropriate; 

·                  Contributes to the planning, implementation, and evaluation of the organization's plan for providing patient care; 

·                  Develops and implements an ongoing departmental quality improvement program which effectively evaluates the process of delivery of the Utilization Management Department and the quality and effectiveness of those services. Uses results to initiate changes to improve practice and service; 

·                  Selects, contracts and coordinates outside services and vendors needed to meet patient care needs; 

·                  Supervises, recruits, selects, assigns, orients, and evaluates professional and ancillary staff; 

·                  Verifies validity of staff licensure; 

·                  Counsels staff on performance expectations and discrepancies; 

·                  Assesses developmental needs of staff and provides educational opportunities; AND

·                  Advocates and supports research in the practice setting.


Risk Management:

·                  Provides the necessary vision and leadership to effectively motivate and direct the Risk Management Department in developing and achieving goals and objectives that are congruous with the values, mission and strategic plan of Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) and the Department of Public Health; 

·                  Using Joint Commission Leadership Standards and CMS Conditions of Participation, provides the framework for planning, directing, coordinating, providing, and improving care, treatment, and services to respond to community and patient needs and improve health care outcomes; 

·                  Responsible for the oversight of the risk management program to identify, analyze and assess clinical risk across the continuum of care; 

·                  Works collaboratively with Quality Management, Patient Safety and Regulatory Affairs staff to enhance the risk management program; 

·                  Conducts apparent and root cause analyses in response to near misses, serious adverse events, and sentinel events to determine the causes of these events; assists in developing corrective action plans and improvement initiatives to eliminate these causes; and assess risks of new programs;

·                  Develops and collaborates in the development of policies and procedures pertaining to the management of risk; 

·                  Manages the Unusual Occurrence system to ensure reported occurrences are properly and timely investigated and assessed; 

·                  Plans and conducts inservice training pertaining to risk management principles, health care law as well as other risk management related subjects; 

·                  Works directly with the City Attorney's Office and with private law firms to facilitate the management of potential and actual claims and litigation involving ZSFG and Ambulatory care within the SF Health Network; 

·                  Furthers the goals of the organization through participation in the management team and the strategic planning process; 

·                  Maintains accurate records, prepares written reports and provides statistical analysis; 

·                  Conducts chart reviews, performs investigations, and critically analyzes adverse outcomes; 

·                  Mentors, develops and supervises the risk management team; AND

·                  Strategically prioritizes large workloads in a thorough and organized manner.


Patient Safety:

·                  Develops, implements and evaluates system wide patient safety plan for Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) that includes the joint commission National Patient Safety Goals (NPSG's), the National Quality Forum Safe practices, California Department of Public Health (CDPH) requirements, CMS requirements, etc.; 

·                  Acts as project manager for hospital wide patient safety teams: 

·                  Agenda planning 

·                  Development of next steps and short term goals 

·                  Organizing and making presentations 

·                  Data analysis and recommendations 

·                  Design and manage reporting systems 

·                  Develop and prepare process documentation 

·                  Establishes a collaborative environment for implementing patient safety efforts across the organization; 

·                  Approaches problem solving and project management with innovation; 

·                  Provides proactive leadership in assessing, managing and evaluation patient safety initiatives; 

·                  Translates patient safety concepts on the Institute for Healthcare Improvement IHI, National Quality Forum, Agency for Healthcare Research and Quality (AHRQ) and other national leaders in patient safety; 

·                  Leads and coordinates hospital wide staff education related to patient safety;

·                  Designs methodologies for patient safety organizational culture assessment; 

·                  Handles issues independently that are significant, complex, political, confidential, multidisciplinary and strategic in nature; AND

·                  Represents ZSFG in a professional and collegial manner.

The 2322 Nurse Manager–Quality Management also performs other related duties as required.

Minimum Qualifications

1. LICENSE: Possession of a valid, including temporary or interim, California Registered Nurse License issued by the Board of Registered Nursing (BRN); AND

2. EDUCATION: Possession of a baccalaureate degree from an accredited college and/or university in Nursing, Nursing Administration or a closely related field; AND

3. EXPERIENCE: Two (2) years (equivalent to 4,000 hours) of verifiable work experience in Nursing Quality Management, Nursing Quality Improvement, or Nursing Utilization Management in an acute care hospital, clinic, home health agency or other health care setting.

Two (2) years (equivalent to 4,000 hours) of additional work experience in Nursing Quality Management, Nursing Quality Improvement, or Nursing Utilization Management in an acute care hospital, clinic, home health agency or other health care setting may be substituted for the educational requirement.


Applicants must meet the minimum qualification requirement by the final filing date unless otherwise noted.


Special Conditions:

The above minimum qualifications reflect special conditions associated with the position(s) to be filled. They may differ from the standard minimum qualifications associated with this classification.


Verification of Experience: http://sfdhr.org/getting-job#verification
Applicants may be required to submit verification of qualifying education and experience at any point during the recruitment and selection process.

Verification of Education: If education verification is required, information on how to verify education requirements, including verifying foreign education credits or degree equivalency, can be found at


Falsifying one's education, training, or work experience or attempted deception on the application may result in disqualification for this and future job opportunities with the City and County of San Francisco.

How To Apply

Applications for City and County of San Francisco jobs are only accepted through an online process. Visit www.jobaps.com/sf to register an account (if you have not already done so) and begin the application process.

·                  Select the desired job announcement

·                  Select “Apply” and read and acknowledge the information

·                  Select either “I am a New User” if you have not previously registered, or “I have Registered Previously”

·                  Follow instructions on the screen

In line with the Official Public Health Order to slow the spread of COVID-19, “shelter-in-place” has been issued for all San Francisco residents that is expected to be in effect until further notice.  As a result, Department of Human Resources (DHR)’s office (located at 1 South Van Ness Avenue, 4th Floor,  San Francisco, CA 94103) is currently closed to the general public. If you have any questions, please feel free to email the Human Resources Analyst listed on this announcement.


Applicants may be contacted by email about this announcement and, therefore, it is their responsibility to ensure that their registered email address is accurate and kept up-to-date. Also, applicants must ensure that email from CCSF is not blocked on their computer by a spam filter. To prevent blocking, applicants should set up their email to accept CCSF mail from the following addresses (@sfgov.org, @sfdpw.org, @sfport.com, @flysfo.com, @sfwater.org, @sfdph.org, @asianart.org, @sfmta.com, @sfpl.org, @dcyf.org, @first5sf.org, @famsf.org, @ccsf.edu).


Applicants will receive a confirmation email that their online application has been received in response to every announcement for which they file. Applicants should retain this confirmation email for their records. Failure to receive this email means that the online application was not submitted or received.

All work experience, education, training and other information substantiating how you meet the minimum qualifications must be included on your application by the filing deadline. Information submitted after the filing deadline will not be considered in determining whether you meet the minimum qualifications.


Applications completed improperly may be cause for ineligibility, disqualification or may lead to lower scores.


If you have any questions regarding this recruitment or application process, please contact the HR Analyst, Catherine Yuen, by telephone at 415-554-2869, or by email at catherine.yuen@sfdph.org

Selection Procedures

Training and Experience Evaluation: (Weight: 100%): Candidates will be prompted to complete a Supplemental Questionnaire as part of the online employment application. The first part of the Supplemental Questionnaire is designed to obtain specific information regarding an applicant's experience in relation to the Minimum Qualifications for this position. Applicants must also complete the official application. The second part of the Supplemental Questionnaire is designed to measure knowledge, skills and/or abilities in job-related areas that have been identified as critical for satisfactory performance in this position.

A passing score must be achieved in order to be placed/ranked on the Eligible List.

All relevant experience, education and/or training must be included in the application to be reviewed during the scoring process. Candidate responses on the Supplemental Questionnaire cannot be changed once submitted. Candidates will be placed on the eligible list in rank order according to their final score on the Supplemental Questionnaire. The department may administer additional position-specific selection procedures to make final hiring decisions.



The certification rule for the eligible list resulting from this examination will be Rule of Ten (10) Scores. Additional selection processes may be conducted by the hiring department prior to making final hiring decisions.


Eligible List:

A confidential eligible list of applicant names that have passed the civil service examination process will be created and used for certification purposes only. An examination score report will be established, so applicants can view the ranks, final scores and number of eligible candidates. Applicant information, including names of applicants on the eligible list, shall not be made public unless required by law. However, an eligible list shall be made available for public inspection, upon request, once the eligible list is exhausted or expired and referrals resolved. The eligible list/score report resulting from this civil service examination process is subject to change after adoption (e.g., as a result of appeals), as directed by the Human Resources Director or the Civil Service Commission.

The duration of the eligible list resulting from this examination process will be of six (6) months, and may be extended with the approval of the Human Resources Director.

Conviction History

As a selected candidate for a job, you will be fingerprinted, and your fingerprints will be sent to the California Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI). The resulting report of your conviction history (if any) will be used to determine whether the nature of your conviction (or arrest, in limited circumstances) conflicts with the specific duties and responsibilities of the job for which you are a selected candidate. If a conflict exists, you will be asked to present any evidence of rehabilitation that may mitigate the conflict, except when federal or state regulations bar employment in specific circumstances, such as:

  • Candidates for positions with the Unified School District and the Community College District may be disqualified from consideration should their conviction history not meet the standards established under the California Education Code.
  • Candidates for positions with the Recreation and Park Department may be disqualified from consideration should their conviction history not meet the standards established under California Public Resources Code 5164.

Having a conviction history does not automatically preclude you from a job with the City.

If you are a selected candidate, the hiring department will contact you to schedule a fingerprinting appointment.

Disaster Service Workers

All City and County of San Francisco employees are designated Disaster Service Workers through state and local law (California Government Code Section 3100-3109). Employment with the City requires the affirmation of a loyalty oath to this effect. Employees are required to complete all Disaster Service Worker-related training as assigned, and to return to work as ordered in the event of an emergency.


Statement on Equity, Diversity, and Inclusion:
At the City and County of San Francisco, we share a commitment to a diverse, inclusive and equitable community. Each member of our organization is responsible and accountable for what they say and do to make San Francisco an inclusive and equitable place to live and work by employing fair and just practices to and for all.

Valid licensure/certification/registration as a requirement to perform the job must be kept current throughout length of employment. Failure to demonstrate/show proof of possession of required valid licensure/certification/registration may result in dismissal and/or termination of employment.

§     Information regarding California Registered Nurse (RN) Licenses may be obtained from the California Board of Registered Nursing, 400 R Street, Suite 4030, P.O. Box 944210, Sacramento, CA 94244-2100, telephone: (916) 322-3350. Web address: http://www.rn.ca.gov/


Cardiopulmonary Resuscitation (CPR) Certificate Requirement/Provision:
Possession of a valid Cardiopulmonary Resuscitation (CPR) Certificate issued by the American Heart Association is required as a provision to employment for all positions. Candidates who do not possess such a certification may participate in this examination process and be appointed to a position(s), but will be required to obtain the certificate within two (2) weeks of hire date and maintain validity throughout length of employment. A photocopy of the valid Cardiopulmonary Resuscitation (CPR) Certificate must be provided to the appropriate supervisor of the appointment within the allotted time frame. Failure to demonstrate/show proof of possession of valid certification within two (2) weeks of hire date and throughout length of employment may result in dismissal and/or termination of employment.


Note on ICARE:

Department of Public Health (DPH) employees are expected to demonstrate world class care in alignment with Zuckerberg San Francisco General Hospital and Trauma Center's (ZSFG) caring framework, ICARE (I-Introduce, C-Connect, A-Ask, R-Respond, E-Exit).


Note on Electronic Health Record (EHR):

The Department of Public Health (DPH) is implementing a unified Electronic Health Record (EHR) system and DPH employees must demonstrate competency in the use of the system that is appropriate for their classification as a condition of employment.


Note on Personal Protective Equipment (PPE):

Some positions in the Department of Public Health will require the use of personal protective equipment (PPE), including but not limited to gloves, gowns, eye and face protection, and face-fitting respirators. The requirement for the use of PPE may come on short or no notice. Facial hair or any condition that interferes with a face-fitting respirator’s seal (i.e. comes between the sealing surfaces of the respirator and the wearer’s bare skin) is not permitted when face-fitting respirators are worn, including during initial or periodic respirator fit-testing. Employees who choose not to shave and do not have either American Disabilities Act (ADA) or Equal Employment Opportunity (EEO) Accommodations do not have the right to alternate work assignments or the option of using a loose-fitting Powered Air Purifying Respirator (PAPR) in place of a Face Fitting Respirator.


Condition of Employment: Highest Educational Achievement
Due to the Clinical Laboratory Improvement Amendment 1988, all applicants who are selected for a position will be required to provide verification of highest level of education achieved. Applicants must meet one of the following conditions:
1. Have earned a doctoral, master's, or bachelor's degree in a chemical, physical, biological or clinical laboratory science (including nursing), or medical technology from an accredited institution; OR
2. Have earned an associate degree in a chemical, physical or biological science (including nursing) or medical laboratory technology from an accredited institution.


Condition of Employment (Security Clearance):
Security clearance as issued by the Sheriff’s Department is required as a condition of employment for all positions at the Jail Health Services. Eligibles who have successfully participated in the examination process, received passing scores and have been selected for hire will be required to obtain the security clearance prior to appointment. A photocopy of the security clearance must be provided to the supervisor on or before date of hire. Failure to demonstrate/show proof of security clearance may result in a dismissal and/or termination of employment.

Note: Failure to meet these criteria and/or ‘Conditions of Employment’ within two (2) weeks PRIOR to the start work date may result in the delay of appointment and/or cancellation of the employment offer. Once appointed, all qualified candidates/employees will be required to retain these qualifications throughout their length of employment. Failure to demonstrate (show proof) of qualifications may result in the termination of employment.


Medical Examination/Drug Testing:
Prior to appointment, at the Department's expense, applicants may be required to take a tuberculosis (TB) screening test, a medical examination and/or drug test.


Terms of Announcement and Appeal Rights:

Applicants must be guided solely by the provisions of this announcement, including requirements, time periods and other particulars, except when superseded by federal, state or local laws, rules or regulations.  [Note: The correction of clerical errors in an announcement may be posted on the Department of Human Resources website at www.jobaps.com/sf.] The terms of this announcement may be appealed under Civil Service Rule 110.4.  Such appeals must be submitted in writing to the Department of Human Resources, 1 S Van Ness Avenue, 4th Floor, San Francisco, CA 94103-5413 by close of business on the 5th business day following the issuance date of this examination announcement.  Information concerning other Civil Service Commission Rules involving announcements, applications and examination policies, including applicant appeal rights, can be found on the Civil Service Commission website at http://sfgov.org/civilservice/rules.


General Information concerning City and County of San Francisco Employment Policies and Procedures can be found at: http://www.sfdhr.org/index.aspx?page=20


Copies of Application Documents: http://sfdhr.org/getting-job#copies


Right to Work: http://sfdhr.org/getting-job#identification


Information on requesting a reasonable ADA Accommodation:


Information regarding requests for Veterans Preference can be found at:


Seniority Credit in Promotional Exams: Information regarding seniority credit can be found at:


Exam Type: CPE
Issued: April 9, 2021
Carol Isen
Human Resources Director
Department of Human Resources
Recruitment ID Number: CBT-2322-109487


All employees hired on or after January 10, 2009 will be required (pursuant to San Francisco Charter Section A8.432) to contribute 2% of pre-tax compensation to fund retiree healthcare. In addition, most employees are required to make a member contribution towards retirement, ranging from 7.5%-13.25% of compensation. For more information on these provisions, please contact the personnel office of the hiring agency.

For more information about benefits, please click here.


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