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Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of January 20, 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:

Claims Review Nurse

Department: Medical Management
Level: Non-supervisory
Reports To: Director, Medical 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: Reviews claims for medical appropriateness for payment. Reviews contracted Medical Group’s provider claims appeals for medical necessity, authorization requirements, contractual requirements, benefit determination and Medicare payment rules. Reviews the medical documentation submitted with the claim appeal to make an informed decision, recommending denial or payment of the claim. Processes all claims review within timeframes. Documents in the authorization system on the applicable authorization and/or the claims notes.
Essential Job Functions:
  • Reviews claims for medical appropriateness for payment, including provider contract status, referral source, coding compliance, medical group’s financial responsibilities, benefit interpretation, coverage policy, etc.
  • Claims review completed within established timeframes to maintain compliance with legislative and delegation standards.
  • Researches in depth genetic testing claims from non-contracted laboratories regarding appropriateness for coverage. Makes recommendation to Senior Team for approval or denial.
  • Reviews claims related ad hoc reports for medical appropriateness, chemotherapy documentation, OB claims, over under-utilization trends and other reports as determined by management.
  • Perform other duties as assigned.
  • Position Qualifications and Requirements:
  • Experience/Specialized Skills: Prior experience in claims review and/or utilization management in a managed care environment. Proficient with computer, Microsoft windows environment.
  • Education/Course(s) /Training: Registered Nurse
    Licensure/Certification: Unrestricted, active California RN License.
    Location: Mira Mesa, San Diego
    Date Posted: January 20, 2021
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    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: January 20, 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: January 20, 2021
    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: Director, Medical Management
    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: 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.
  • Other duties as assigned.
  • 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 20, 2021
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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