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Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of January 22, 2020)


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:

Eligibility Assistant

Department: Claims & Eligibility
Level: Non-supervisory
Reports To: Manager, Claims & Eligibility
Private Health Information (PHI): Position requires "read only" access to member authorizations and read and write access to member 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: Researches eligibility issues regarding active dates, termed dates, assigned primary care physicians, and address corrections for members enrolled with one of our groups, and updates the EZCap system accordingly.
Essential Job Functions:
  • Works daily reports from member notes and claim notes to verify, clarify, and update member eligibility. Looks up member on health plan websites and/or calls the plans for verification. Enrolls and updates individual members in EZ-Cap. Responds back via EZ-Cap member notes. All reports must be completed by the end of the day.
  • Researches "not on file" claims, within 1 day of receipt of claim by the production area. If eligibility is verified with one of our groups accurately updates the EZCap system and notifies Production Assistant. If eligibility is located with another group, or no eligibility is located, notifies Production Assistant where to forward the claim, or to return the claim back to the provider for health plan card.
  • Researches the EZCap system and health plan eligibility information via their website or telephone for eligibility verifications e-mailed to Eligibility Inquiry.
    o Routine requests within 1 business day
    o Stat/Urgent requests within 2 hours of the request.
  • Updates member address information from member updates and returned mail.
  • Assists Eligibility Analysts as needed.
  • Position Qualifications and Requirements:
  • 2 years of managed care eligibility experience. Strong data entry skills and working knowledge of the Internet.
  • High School diploma

  • Licensure/Certification: N/A
  • Location: Mira Mesa, San Diego
    Date Posted: January 22, 2020
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Medical Assistant - Performance Improvement

    Department: Network Management
    Level: Non-supervisory
    Reports To: Director, Network Management
    Private Health Information (PHI): Position requires "read only" access to member authorizations, 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: Supports performance improvement in the Network Management Department by assisting in the design and execution of targeted data mining projects. Reconciles data with select health plans and conducts chart reviews to satisfy HEDIS specifications.
    Essential Job Functions:
  • Data Gathering - Work with Provider Relations Representatives as needed to gain access to the appropriate office contacts for data mining. Scheduling on-site visits at provider offices to review paper and electronic medical records utilizing HEDIS specifications. Meet or exceed accuracy standard of 95%.
  • File maintenance / Data Tracking / Research – Prepare reports with targeted health plans including supplemental data, gap analysis and other ad hoc activities to monitor quality data. Review data sources from internal and external systems to identify quality data.
  • Member outreach - Where indicated, contact members to discuss needed screenings.
  • Meetings - Represent MSO in meetings with providers and the project health plans to reconcile data listings.
  • Performs other duties as assigned.
  • Position Qualifications and Requirements:
  • Minimum two years experience working in a clinical setting maintaining documentation. Understanding of provider office operations.
  • Proficiency with multiple EHR systems. Ability to read medical records.
  • Strong customer service and professional communication skills, both written and verbal, required.
  • Basic knowledge of HEDIS measures.
  • Excellent organizational and time management skills and ability to handle multiple tasks.
  • Proficient in Outlook, Excel, and Word. Ability to learn company-specific software programs (Cozeva).
  • Demonstrated ability to handle confidential or sensitive issues in a responsible manner.
  • Demonstrated professional office demeanor.

  • Licensure/Certification: Medical Assistant (MA) Certification, reliable transportation, a valid CA Driver's License, and current car insurance meeting CA standards.
  • Location: Mira Mesa, San Diego
    Date Posted: January 22, 2020
    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: Director, Medical 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 authorization requests for medical necessity, utilizing Health Plan and Medicare Criteria in the review determination. Processes all requests within established time frames. Documents all steps of process in authorization system, utilizes industry standard denial language for denial letters.
    Essential Job Functions:
  • 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.
  • 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: January 22, 2020
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Utilization Management Representative

    Department: Medical Management
    Level: Non-supervisory
    Reports To: Manager, Health Services
    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: Performs data entry of referral requests. Contacts Health Plans for medical policies or benefit interpretations. Contacts physician offices to obtain additional clinical information.
    Essential Job Functions:
  • Performs data entry of referral request images accurately on a daily basis to meet turnaround time standards.
  • Contacts Health Plans for medical policies or benefit interpretations.
  • Contacts physician offices as directed by Case Manger to obtain additional clinical information. Issues pended letter if information is not received within established timeframes.
  • Works Status 7 (Requested) Referrals daily, checking benefits as applicable, changing status to N (Nurse Review) to facilitate timely referral processing.
  • Sorts and distributes faxed referral images into designated employee folders on a rotating shared sorting schedule. Attaches electronic faxed medical record images to EZ-Cap authorization.
  • Attaches copy of pre-service denial letter to denied referral with supporting documentation.
  • Notifies requesting physician by telephone or fax within four hours of all urgent request decisions, if directed by Outpatient Case Manager.
  • Position Qualifications and Requirements:
  • Experience/Specialized Skills:
        o Knowledge of medical terminology, ICD and CPT coding.
        o Proficient with computer, Microsoft Windows environment.
  • Education/Course(s)/Training: High School Diploma
  • Licensure/Certification: N/A
  • Location: Mira Mesa, San Diego
    Date Posted: January 22, 2020
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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