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Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of September 8, 2022)


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: 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 a plus
  • Education/Course(s) /Training: High School Diploma
    Licensure/Certification: NA
    Location: Mira Mesa, San Diego
    Date Posted: September 8, 2022
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Credentialing Coordinator

    Department: Medical Management
    Level: Non-supervisory
    Reports To: Director, Medical Management
    Private Health Information (PHI): Position requires "read only" to member authorizations, 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 credentialing applications for completeness, completes primary source verification and prepares applications for committee review. Maintains credentialing database on all credentialed providers.
    Essential Job Functions:
  • Reviews credentialing applications for completeness, and scans into database. Obtains current copies of medical license, DEA license and malpractice insurance and verifies with appropriate agency.
  • Complete primary source verification on all initial applicants and on all providers at time of re-credentialing within 180 days of application being signed..
  • Maintains credentialing database on all credentialed providers, updates information upon completion of re-credentialing, and as various documents expire.
  • Prepare credentialing packets for each Medical Group’s board meetings so review can be made within 180 days of application being signed.
  • Sends out initial credentialing packets to potential new providers, as directed. Sends out re-credentialing packets to providers 90 days prior to re-credentialing due date. Follows up with providers when applications are not returned timely.
  • Pulls credentialing files, reviews and prepares files for health plan delegation audits. Runs ad hoc reports from available databases.
  • Position Qualifications and Requirements: Experience/Specialized Skills:
  • Prior physician credentialing experience.
  • Proficient with computer, Microsoft windows environment.
  • Education/Course(s) /Training: Associate degree preferred.
    Licensure/Certification: NA
    Location: Mira Mesa, San Diego
    Date Posted: September 8, 2022
    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:
  • 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.
    Location: Mira Mesa, San Diego
    Date Posted: September 8, 2022
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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