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Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of June 9, 2021)


Southern California Physicians Managed Care Services is San Diego's premier provider of medical administrative services including claims payment, contracting and utilization management.

Current Career Opportunities:

Southern California Physicians Managed Care Services has the following career opportunities available:

Complex Case Manager

Department: Medical Management
Level: Non-supervisory
Reports To: Manager, Health Services
Private Health Information (PHI): Position requires "read only" access to member authorizations, "read and write" access to claims and eligibility
Job Classification: Non-Exempt
Job Type: Full time - Four-Day 10 hour days, Monday - Thursday
Pay Rate: Salary is based on qualifications and experience
Position Summary: The complex case manager role is a collaborative position, where at risk members are identified through multiple sources. Assessment and re-assessment on a regular basis of these members, development of a member specific plan of care to aid in the healthcare process. Coordinating care with multiple entities to ensure member receives resources to optimize health. Summary reports on the outcome/ effectiveness and satisfaction of the members enrolled in the complex case management programs.
Essential Job Functions: Identification of at-risk members through various sources including but not limited to:
  • Referrals from case managers – MSO and Health Plan
  • Multiple re-admissions, multiple ER visits
  • PCP/ Specialist referrals
  • Health Plan Health Risk Assessments
  • Health Plan notices of potential high-risk members – SNP or multiple medication reviews
  • Multiple co-morbidities identified from various sources
  • High utilization of outpatient services
  • Discharge follow up phone calls

  • Assessment of at-risk members:
  • Utilize on-line Care Management System – EZ-Care
  • Prioritizing and determining risk level (low, medium, high) of assessed members
  • Completes EZ Care Health Risk Assessment
  • Develops member specific care plan, uses MCG tools as a resource, documenting care plan initial and updates in EZ-Care
  • Incorporation of Health Plan’s Health Risk Assessments or Care Plans into member’s care plan as appropriate

  • Re-assessment/ follow up of at-risk members through the following:
  • Re-assess member’s risk level
  • Updates care plan accordingly
  • Sets schedule with member for telephonic management based on individual needs
  • Closes cases when goals have been met, level of care changes, etc.

  • Co-ordination of Care
  • Co-ordination with PCP/ Specialist office to facilitate timely access to care
  • Referrals to community resources/ wellness programs
  • Authorizes ancillary services as needed
  • Works with health plans to refer members to disease management programs
  • MSO and Health Plan Case Manager coordination

  • Reporting standards for Complex Case Management:
  • Complies monthly reports on open and closed cases by prioritizing levels
  • Separate reporting for each health plan and by product, plus summary reports
  • Sending satisfaction/ experience surveys to members who have completed the case management program, identifying opportunities for improvement if applicable
  • Evaluating the effectiveness of the case management program on an annual basis

  • Other duties as assigned
    Position Qualifications and Requirements:
  • Experience/Specialized Skills: Prior experience in case management or utilization management in a managed care environment.
  • Proficient with computer, Microsoft Windows environment.
  • CCM and Bi-lingual preferred.
  • Education/Course(s) /Training: Bachelor’s degree, Registered Nurse
    Licensure/Certification: Registered Nurse, active California License
    Location: Mira Mesa, San Diego
    Date Posted: June 9, 2021
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Outpatient Case Manager - RN

    Department: Medical Management
    Level: Non-supervisory
    Reports To: Manager, Utilization Management
    Private Health Information (PHI): Position requires "read and write" access to member authorizations, "read only" access to claims and eligibility
    Job Classification: Non-Exempt
    Job Type: Full time - Four-Day 10 hour days, Monday - Thursday
    Pay Rate: Salary is based on qualifications and experience
    Position Summary: Reviews contracted Medical Group’s referral requests for medical necessity, determines which requests need Medical Director review, obtains sufficient medical documentation for an informed decision. Processes all requests within established timeframes. Documents all steps of process in authorization system, utilizes industry standard denial language for denial letters.
    Essential Job Functions:
  • This description is not exhaustive and may be modified on a temporary or regular basis at the discretion of SCPMCS. SCPMCS expects that its' employees will need to assume other "non-essential functions" not listed herein which support company business objectives; this may include duties which fall outside of normal position scope
  • Reviews contracted Medical Group’s referral requests for medical necessity. Consideration is given to the appropriateness of the setting, place of service, health plan’s benefits and criteria of the requested services and utilizing contracted providers. Documents process in authorization notes
  • Refers all medical necessity denials to the physician reviewers for review determination. Processes denials within established time frames. Documents in the authorization system the denial reason, utilizing the industry standard denial letter language, outlines alternative services available.
  • Reviews requests within established time frames for urgent, routine and retro requests to maintain compliance with legislative and accreditation standards.
  • Obtains additional information for Medical Director’s review of appeals. Coordinates with health plan to meet time frames for expedited appeals.
  • Contacts out of network or tertiary facilities for clinical information on patients authorized for services at the facility. Coordinates discharge needs for these members with hospital case manager.
  • Notifies health plan representative of potential transplants, out of area second opinions, experimental or investigatory requests.
  • Position Qualifications and Requirements:
  • Experience/Specialized Skills: Prior experience in utilization management in a managed care environment. Proficient with computer, Microsoft Windows environment.
  • Education/Course(s) /Training: Registered Nurse
    Licensure/Certification: Registered Nurse, active California License. Must have reliable transportation, valid California Driver's License and proof of insurance.
    Location: Mira Mesa, San Diego
    Date Posted: June 9, 2021
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Provider Relations/Contracts Manager

    Department: Network Management
    Level: Supervisory
    Reports To: Director, Network Management
    Private Health Information (PHI): Position requires "read only" access to member authorizations, "read and write" access to member claims and eligibility
    Job Classification: Exempt
    Job Type: Full time - Four-Day 10 hour days, Monday - Thursday
    Pay Rate: Salary is based on qualifications and experience
    Position Summary: Supervises the daily activities of the Provider Relations Representatives. Participates in contracting activities and provides overall administrative management support to the Network Management Department. Prepares reports as needed to monitor compliance with departmental and organizational objectives.
    Essential Job Functions:
  • Staff Supervision - Supervises the daily activities of the Provider Relations staff, employee work schedules and work assignments to ensure effective business operations. Takes appropriate corrective action when required to improve employee performance in accordance with policy. Participates in the interviewing and hiring of new staff. Provides staff training as required.
  • Contracts/Agreements - Prepares appropriate contracting documents including rates, language, and amendments. Assists with contract negotiations and network development as assigned
  • Client Relations - Works with the Director of Network Management to maintain positive and productive relationships between department staff, health plans, providers and members. Tracks and monitors network membership, PCP and specialist compliance with IPA procedures and programs. Designs provider communications and education materials to enhance provider cooperation and performance. Works effectively with appropriate individuals to resolve staff, member and provider issues/complaints, referring specialized issues to the appropriate department. Tracks and communicates resolution to all parties.
  • Administrative Management – Assist with maintaining provider contract files. Ensure that all Provider Relations activity is documented for future reference. Oversees provider roster preparation for client purposes as well as proofing rosters with the health plans. Prepares departmental reports as required.
  • Meetings - Represent senior management at meetings with clients in a professional and appropriate manner. Demonstrates presentation skills that reflect positively on the organization.
  • Performs other duties as assigned.
  • Position Qualifications and Requirements:
  • Prior supervisory and managed care experience required.
  • Minimum of 3 years of operations experience in a health plan, MSO or medical group environment required.
  • Experience negotiating with physicians and vendors and preparing agreements.
  • Knowledge of various reimbursement methodologies.
  • Strong customer service and professional communication skills, both written and verbal, required.
  • Excellent organizational and time management skills and ability to handle multiple tasks.
  • Advanced knowledge of Microsoft Word, Excel, email and intermediate knowledge of PowerPoint, Access and other applications/information systems pertinent to managing and monitoring contracts.
  • Familiar with claims processes, CPT, ICD-10 coding desired.
  • Education/Course(s) /Training: Associates Degree required or a combination of related experience and training. Bachelor’s Degree preferred.
    Licensure/Certification: Reliable transportation, a valid CA Driver's License, and current car insurance meeting CA standards.
    Location: Mira Mesa, San Diego
    Date Posted: June 9, 2021
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Provider Relations Representative

    Department: Network Management
    Level: Non-supervisory
    Reports To: Director, Network Management
    Private Health Information (PHI): Position requires "read only" access to member authorizations, "read and write" access to member claims and eligibility
    Job Classification: Exempt
    Job Type: Full time - Four-Day 10 hour days, Monday - Thursday
    Pay Rate: Salary is based on qualifications and experience
    Position Summary: Primary liaison between the client and MSO for the delivery of Managed Care Administrative Services. Responsible for concise and complete explanations of all phases of services from each MSO Department to the assigned IPA groups and resolving issues between them.
    Essential Job Functions:
  • Coordinates and co-chairs all client board and regional meetings within assigned territory. Maintains official copies of minutes, agendas and credentialing signatures at the MSO’s office. Sends announcements regarding scheduled meetings, makes phone calls to verify attendance (quorum), orders refreshments and sets up/breaks down the meetings. Prepares, or directs the preparation of, agendas, handouts and meeting minutes. Represents management at all meetings with clients in an appropriate and professional manner.
  • Serves as a resource for internal referrals on provider issues. Supports the Client Services Department in resolving provider issues and responds to training needs identified by other MSO departments such as Claims and Medical Management. Interfaces with Health Plan staff as required. Effectively problem solves issues as identified; documents all contact with providers/office staff in the provider’s file. Monitors client needs to evaluate satisfaction levels, and identifies trends and areas requiring improvement.
  • Manages the interface between providers, the MSO and the health plans. Remains accessible to providers and their office staff. Leaves specific instructions about how to be reached within and outside the office. Utilizes email and the cell phone to maintain productivity within and outside the office. Schedules regular visits with physician offices to provide education, training and customer service. Establishes and maintains strong, productive relationships with office staff by providing superior customer service and effectively solving issues. Stays current with activities in the market by developing an open rapport with the offices. Represents management at all meetings with clients in an appropriate and professional manner.
  • Recruits providers in designated geographic areas, negotiates provider contracts within specified guidelines and assists the Director of Network Management in all phases of network negotiations and contracting. Investigates interested providers for consideration by the regional committee. Notifies health plans and appropriate internal departments of provider contract and status changes. Functions as a messenger between plans and IPA clients, as applicable, during contracting functions.
  • Develops provider manuals, provider directories, provider communications, and other related materials; and facilitates the distribution of such information.
  • Performs other duties as assigned.
  • Position Qualifications and Requirements:
  • Proven experience in managed care operations, with a minimum of 3 years experience in managed care.
  • Knowledge of CPT, ICD-10 Codes.
  • Exposure to contract language, rates, and coverage definitions.
  • Must have the ability to communicate in a professional manner, have problem solving skills and work independently.
  • Excellent organizational and interpersonal skills.
  • Ability to work effectively with a wide variety of people at all levels.
  • Experience training individuals on managed care policies and procedures in small or large groups. Presentation skills.
  • Experience organizing meetings and taking minutes.
  • Computer literacy, including competence with various word processing and managed care programs. Microsoft Office familiarity required.
  • Education/Course(s) /Training: Associates Degree required or a combination of related experience and training. Bachelor’s Degree preferred.
    Licensure/Certification: Reliable transportation, a valid CA Driver's License, and current car insurance meeting CA standards.
    Location: Mira Mesa, San Diego
    Date Posted: June 9, 2021
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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