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Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of June 5, 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: June 5, 2019
    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: June 5, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    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.
  • String 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: June 5, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Quality Management Coordinator

    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: Provides internal and external health plan notification of provider adds, terms and changes. Updates and distributes provider directories. Completes intake form and requests appropriate medical records for member complaints and provider appeals.
    Essential Job Functions:
  • Completes provider profile form for internal and external health plan notifications of provider adds, terms and changes.
  • Completes intake form accurately for each complaint or appeal received from members or providers. Request appropriate medical records, assembles all documents for additional medical review.
  • Forwards member complaint/appeal to Health Plan with supporting documentation within the required time frames as specified by the Health Plan request.
  • Enters all complaint and appeal data accurately into the database on a concurrent basis.
  • Updates and distributes provider directories on a monthly basis. Works closely with Network Management and the Credentialing Coordinator to include the most current information.
  • 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: Prior managed care experience with a medical group or health plan. Customer service skills with a health plan members or providers. Proficient with computer, Microsoft Windows environment, Access database management.
  • Education/Course(s)/Training: Associates Degree
  • Licensure/Certification: N/A
  • Location: Mira Mesa, San Diego
    Date Posted: June 5, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Senior Managed Care Accounting Analyst

    Department: Finance
    Level: Supervisor
    Reports To: Chief Financial Officer
    Private Health Information (PHI): Position requires "read only" access to member authorizations, 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: Responsible for accounting and financial statement preparation for assigned client(s). Responsible for backing up the Controller on MSO related accounting, financial statement preparation and financial management of the AP and AR processes.
    Essential Job Functions:
  • Produces and maintains monthly client general ledger, balance sheet, income statement, cash flow statements and plan performance reports.
  • Manages the check EFT payment process for fee for services claims for clients
  • Updates and maintains the primary care capitation system rates. From the capitation and membership compiles prepares the primary care capitation, capitation reports and enrollment reports.
  • Reconciles client’s bank account.
  • Calculates accrual for IBNR (incurred but not reported expenses).
  • Reviews and accounts for monthly capitation revenue reports from health plans. Ensures capitations revenue has been received and, in the amounts, expected based on membership and current contracted rates.
  • Calculates payments owed for recurring monthly client expenses (i.e stop loss premium, administrative fees, specialty capitation and all other vendor expenses).
  • Responds to client and SCPMCS department inquiries within 24 hours including request for capitation verification.
  • Reporting as requested by the Chief Financial Officer.
  • Backs up the Controller duties, assuming some permanent duties as requested. Backs up the HR Payroll Process.
  • Position Qualifications and Requirements:
  • Min of (5) years of experience in accrual financial accounting and reporting.
  • Min of (2) years of supervisory experience preferred.
  • Healthcare experience in an MSO or Health Plan preferred.
  • Proficient in Microsoft Windows database and spreadsheet programs required*
  • Proficient in accounting software required* (Peachtree desired).
  • Proven mathematical skills (i.e. calculations of percent, use of multipliers).
  • Strong attention to detail and accuracy and the ability to detect errors required*

  • Education/Course(s)/Training: Bachelor’s degree in accounting required
  • Licensure/Certification: CPA a plus
  • Location: Mira Mesa, San Diego
    Date Posted: June 5, 2019
    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 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: June 5, 2019
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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