Our Organization  |  Clients  |  News Room  |  Career Opportunities
 

Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of August 15, 2019)


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:

Inpatient/SNF Case Manager

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: Under the supervision of the Director of Medical Management, the Inpatient/SNF Case manager reviews Medical Group’s inpatients, rehab, long term acute (LTAC), and skilled nursing admissions on a concurrent basis for medical necessity. Reviews ongoing stays for continuing care criteria being met. Coordinates discharge plans with the facility’s case managers for timely discharge.
Essential Job Functions:
  • Reviews the Medical Group's inpatients on a concurrent basis for medical ecessity. Consideration is given to appropriateness of the setting, intensity and severity of services being provided and the member's benefits. Documents the review in the authorization system daily. Utilizes hospital medical record systems for on-line information.
  • Reviews all long-term acute care and skilled nursing admissions for appropriateness of the admission and ongoing for continuing care criteria being met.
  • Coordinates discharge plans with hospital or skilled nursing case managers for timely discharge or transfer to lower level of care.
  • Issues Notice of Medicare Non-Coverage to all rehab level of care and senior skilled nursing members prior to discharge. Issues exhaustion of benefits letters. Issues authorizations for post-discharge services.
  • Contacts out of network facilities for clinical information for any medical Group's member admitted to the facility. Coordinates transfer to contracted facility as appropriate.
  • Discusses the medical necessity of continued stay with the attending physician or the Medical Director when level of care appears to be inappropriate or member does not meet criteria. Issues hospital denial for members not meeting acute level of care.
  • Position Qualifications and Requirements:
  • Experience/Specialized Skills: Prior experience in utilization management or discharge planning 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: August 15, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


    Back To Top

    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 and read and write access to member claims and eligibility
    Job Classification: Non-Exempt
    Job Type: Temporary (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 assigning 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: August 15, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


    Back To Top

    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: August 15, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


    Back To Top

    Performance Analyst (Certified Coder)

    Department: Network Management
    Level: Non-supervisory
    Reports To: Director, Network Management
    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: Certified Medical Coder will serve on a team to audit quality and HCC reporting. HCC experience is desired. Familiar with quality reporting through HEDIS/NCQA/AMP in California. Participates in physician education as needed to enhance documentation/coding accuracy. Professional verbal and written communication skills. Strong computer literacy required to utilize our documentation system and manage data in spreadsheets. Ability to work with changing priorities and willing to attend webinars to stay updated on program requirements.
    Essential Job Functions:
  • Establishes / generates reports and analyses the information against contract incentive programs and health plan data.
  • Receives HCC senior diagnoses and process then into the tracking programs. Recommends training opportunities and participates in provider trainings as needed. Audits and interfaces with outside coding vendors.
  • Recommends solutions to identify performance issues. Participates in webinars and conference as needed to stay abreast of IHA / NCQA requirements.
  • Serves as the user expert of software systems. Audits software accuracy from time to time. Attends user meetings and reports systems issues to the vendor.
  • Tracks and submits audit data for program compliance. Interacts with auditor to submit annual scores.
  • Performs other duties as assigned.
  • Position Qualifications and Requirements:
  • Minimum three years Healthcare Industry experience.
  • Knowledge of managed care concepts and healthcare delivery systems; understanding of health insurance industry and products.
  • Excellent organizational and interpersonal skills.
  • Experience working with CPT and ICD-10 codes and reading claims forms / reports.
  • Organized self-starter with follow through. Ability with changing priorities and varying deadlines.
  • Strong computer literacy, including competence with database and spreadsheet programs.
  • Microsoft Office products familiarity required.
  • Associates Degree with equivalent combination of experience in healthcare and/or information systems. Completed coursework in coding.

  • Licensure/Certification: Coding
  • Location: Mira Mesa, San Diego
    Date Posted: August 15, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


    Back To Top

    Performance Improvement Manager

    Department: Network Management
    Level: Supervisory
    Reports To: Director, Network Management
    Private Health Information (PHI): Position requires "read only" access to member authorizations and 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: Provide Leadership and operational management for quality and risk programs across the provider network. Supervises the daily activities of the performance team. Develops and implements quality improvement initiatives. Collaborates with internal departments and health plans to ensure compliance with IHA, HEDIS and CMS Stars initiatives. Responsible for annual quality data reporting and the audit process. Oversees the annual assessment program to ensure accurate documentation.
    Essential Job Functions:
  • Reporting – Monitor IPA performance and staff productivity. Analyze data to measure program effectiveness.
  • Programs – Develop and monitor initiatives for ongoing IPA improvement. Create tools and materials for training and performance monitoring.
  • Client Relations – Works with the Director of Network Management to maintain positive and productive relationships between department staff, health plans, providers and members. Works with Provider Relations team to communicate with physicians and their staff. Meet with physicians as needed.
  • Staff Supervision – Supervises the daily activities of the performance staff. Employee work schedules and work assignment to ensure effectiveness 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.
  • Represents the MSO in state/regional meetings and conferences specific to quality. Including but not limited to IHA, health plans, IPA meetings, vendor user conferences.
  • Performs other duties as assigned.
  • Position Qualifications and Requirements:
  • Bachelor’s Degree in health care administration, public health, nursing, or other related field or equivalent work experience.
  • Prior supervisory experience managing diverse areas of responsibility.
  • Minimum of 3 years of operations experience in a health plan, MSO or medical group environment and have a working knowledge of managed care principles.
  • Strong customer service and professional communication skills, both written and verbal, required.
  • Excellent organizational and time management skills. Ability to work on multiple complex projects simultaneously.
  • Advanced knowledge of Microsoft Word, Excel, email and intermediate knowledge of PowerPoint, Access and other applications/information system pertinent to managing data and conducting training sessions.
  • Experience in data analysis.
  • Familiar with claims processes, CPT, ICD-10 and HCPCS coding desired.

  • Licensure/Certification: Certificate in coding is a plus*; reliable transportation, a valid CA Driver's License, and current car insurance meeting CA standards.
  • Location: Mira Mesa, San Diego
    Date Posted: August 15, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


    Back To Top