Our Organization  |  Clients  |  News Room  |  Career Opportunities
 

Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of October 7, 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:

Complex 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: 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
  • 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.
  • 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.
  • CCM and Bi-lingual preferred
  • Location: Mira Mesa, San Diego
    Date Posted: October 7, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


    Back To Top

    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: October 7, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


    Back To Top

    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: October 7, 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: October 7, 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: October 7, 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: October 7, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


    Back To Top

    Utilization Management Representative

    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 Utilization Management Representative will perform data entry of referral requests. The Utilization Management Representative will contact Health Plans for medical policies or benefit interpretations and contact 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: October 7, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


    Back To Top