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Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of September 12, 2024)


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:

Client Services Representative (Bilingual English/Spanish)

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. "Write" access to member notes only.
Job Classification: Non-Exempt
Job Type: Full time - Four-Day 10 hour days, Monday - Thursday
Pay Rate: $17.90 - $21.92 an hour. Salary is based on qualifications and experience.
Position Summary: Provides internal and external clients with information related to managed care services; such as Utilization Management, Claims Processing, IPA Management, Eligibility and Contracting.
Essential Job Functions:
  • Initiates and coordinates resolution of inquiries from both internal and external clients.
  • Obtains appropriate data to research issues, including but not limited to medical records, claim/authorizations copies and other contributing information.
  • Provides clients with immediate status of authorizations, claims processed, eligibility, physician availability and demographic information.
  • Processes and researches client issues via EZCAP System. Enters member notes on all issues requiring additional action.
  • Responds to clients via phone, e-mail, fax or letter on issues that cannot be resolved during the course of the initial phone contact.
  • Cross-trains into other Network Management positions as needed, performs other duties as assigned.
  • Position Qualifications and Requirements:
  • Two years experience in a healthcare setting
  • One year experience working in a customer service/call center environment
  • Ability to answer a minimum of 70 calls per day
  • Ability to type a minimum of 40 wpm
  • Excellent communications skills
  • Basic knowledge of Microsoft Office Products
  • Knowledge of CPT, ICD-10 codes desired
  • Knowledge of basic managed care principles and processes desired
  • Bilingual in Spanish a plus
  • Education/Course(s) /Training: High School Diploma required.
    Licensure/Certification: N/A
    Location: Mira Mesa, San Diego
    Date Posted: September 12, 2024
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Clinical Compliance Nurse

    Department: Medical Management
    Level: Non-Supervisory
    Reports To: Director, Medical Management
    Private Health Information (PHI): Position requires "read and write" access to member authorizations and "read only" access to member claims and eligibility.
    Job Classification: Non-Exempt
    Job Type: Full time - Four-Day 10 hour days, Monday - Thursday
    Pay Rate: $42.20 - $56.46 an hour. Salary is based on qualifications and experience.
    Position Summary: Supports and facilitates the delegation processes across product lines by assisting with delegation oversight audits with the health plans. Ensuring policies/procedures, documentation and reports are in compliance with regulatory and applicable accreditation guidelines, and are meeting required standards.
    Essential Job Functions:
  • Schedule audit and prepare documents for individual health plan UM audits. This would include file selection and assembling of all the documents for the audit.
  • Review and update on annual basis Medical Management Program, Policies and Procedures to comply with changes in NCQA and regulatory requirements to meet annual health plan audit requirements.
  • Participate in health plan CMS audits, query the databases, completing CMS universe templates, submission of templates, as applicable.
  • Completion and submission of ICE semi-annual health plan specific UM reports.
  • Respond to corrective action plans timely, as applicable.
  • Completion and submission of ad hoc health plan report requests-NCQA denial, DMHC denials for specified timeframe, CMS validation submission reports
  • Other duties as assigned: Claims Review.
  • Position Qualifications and Requirements: Experience/Specialized Skills::
  • Prior experience in health plan, medical group delegation, NCQA surveys or auditing experience.
  • Utilizes strong verbal and written communication skills.
  • Proficient with computer, Microsoft windows environment.
  • Education/Course(s) /Training: Registered Nurse
    Licensure/Certification: Registered Nurse, active California License.
    Location: Mira Mesa, San Diego
    Date Posted: September 12, 2024
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Provider Relations Representative

    Department: Network Management
    Level: Non-Supervisory
    Reports To: Director, Network Management
    Private Health Information (PHI): Position requires "read only" access to member eligibility, claims, and authorizations, "read and write" access to member notes and provider notes.
    Job Classification: Non-Exempt
    Job Type: Full time - Four-Day 10 hour days, Monday - Thursday
    Pay Rate: $27.89 - $35.27 an hour. Salary is based on qualifications and experience.
    Position Summary: Primary liaison between the client and MSO for the delivery of Managed Care Administrative Services. Responsible for concise and complete explanations of all phases of services from each MSO Department to the assigned IPA groups and resolving issues between them.
    Essential Job Functions:
  • Coordinates and co-chairs all client board and regional meetings within assigned territory. Maintains official copies of minutes, agendas and credentialing signatures at the MSO’s office. Sends announcements regarding scheduled meetings, makes phone calls to verify attendance (quorum), orders refreshments and sets up/breaks down the meetings. Prepares, or directs the preparation of, agendas, handouts and meeting minutes. Represents management at all meetings with clients in an appropriate and professional manner.
  • Serves as a resource for internal referrals on provider issues. Supports the Client Services Department in resolving provider issues and responds to training needs identified by other MSO departments such as Claims and Medical Management. Interfaces with Health Plan staff as required. Effectively problem solves issues as identified; documents all contact with providers/office staff in the provider’s file. Monitors client needs to evaluate satisfaction levels, and identifies trends and areas requiring improvement.
  • Manages the interface between providers, the MSO and the health plans. Remains accessible to providers and their office staff. Leaves specific instructions about how to be reached within and outside the office. Utilizes email and the cell phone to maintain productivity within and outside the office. Schedules regular visits with physician offices to provide education, training and customer service. Establishes and maintains strong, productive relationships with office staff by providing superior customer service and effectively solving issues. Stays current with activities in the market by developing an open rapport with the offices. Represents management at all meetings with clients in an appropriate and professional manner.
  • Recruits providers in designated geographic areas, negotiates provider contracts within specified guidelines and assists the Director of Network Management in all phases of network negotiations and contracting. Investigates interested providers for consideration by the regional committee. Notifies health plans and appropriate internal departments of provider contract and status changes. Functions as a messenger between plans and IPA clients, as applicable, during contracting functions.
  • Develops provider manuals, provider directories, provider communications, and other related materials; and facilitates the distribution of such information.
  • Internet portal user set-up, training, documentation, communication and troubleshooting with vendors as necessary.
  • Completes other duties as requested and assigned.
  • Position Qualifications and Requirements:
  • Proven experience in managed care operations, with a minimum of 3 years experience in managed care.
  • Knowledge of CPT, ICD-10 Codes.
  • Exposure to contract language, rates, and coverage definitions.
  • Must have the ability to communicate in a professional manner, have problem solving skills and work independently.
  • Excellent organizational and interpersonal skills.
  • Ability to work effectively with a wide variety of people at all levels.
  • Experience training individuals on managed care policies and procedures in small or large groups. Presentation skills.
  • Experience organizing meetings and taking minutes.
  • Ability to conduct on-line meetings and conference calls.
  • Must have reliable transportation, valid California Driver’s License, and proof of insurance.
  • Computer literacy, including competence with various word processing and managed care programs. Microsoft Office familiarity required.
  • Education/Course(s) /Training: Associates Degree required with a combination of related experience and training. Bachelor’s Degree preferred.
    Licensure/Certification: N/A
    Location: Mira Mesa, San Diego
    Date Posted: September 12, 2024
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Supervisor, Utilization Management

    Department: Medical Management
    Level: Supervisory/Management
    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: Exempt
    Job Type: Full time - Four-Day 10 hour days, Monday - Thursday
    Pay Rate: $48.26 - $62.50 an hour. Salary is based on qualifications and experience
    Position Summary: Provides daily supervision to case managers and support staff. Assists with orientation and training of new staff. Documents employee discussions and disciplinary actions when appropriate.
    Essential Job Functions:
  • Provides daily assignments and supervision to all case managers and UM Rep. Acts as a resource for all staff for health care delivery systems issues. Reassigns staff from their usual areas to provide coverage during staff absences.
  • Serves as department’s liaison for internal departments for questions and expedited requests from Client Services or Provider Reps.
  • Assists in orientation of new staff, focusing on the UM Rep positions. Documentation of employee’s discussions and disciplinary actions, as appropriate.
  • Reviews daily census of inpatients for accuracy. Acts as a resource for the Inpt. staff for health care delivery system options. Provides guidance to staff obtaining ad hoc contracts to facilitate timely discharges
  • Monitors, edits, as applicable, and the approval of employee’s time in the organization’s timekeeping software.
  • Position Qualifications and Requirements:
  • Prior supervisory experience in a managed care setting.
  • Utilizes astrong verbal and written communication skills.
  • Ability to manage diverse staff includes exempt and non-exempt staff.
  • Requires complex problem-solving ability.
  • Thorough understanding of health plan managed care benefits and matrices of responsibility between various payers.
  • Proficient with computer, Microsoft windows environment.
  • Education/Course(s) /Training: Bachelor’s Degree, Registered Nurse
    Licensure/Certification: Registered Nurse, active California License. Reliable transportation, valid California Driver’s License and proof of insurance.
    Location: Mira Mesa, San Diego
    Date Posted: September 12, 2024
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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