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Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of February 8, 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: January 25, 2024
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Data Management Specialist

    Department: Information Technology
    Level: Non-Supervisory
    Reports To: Directory of Information Technology and Security
    Private Health Information (PHI): Position has complete access to electronic PHI.
    Job Classification: Exempt
    Job Type: Full time - Four-Day 10 hour days, Monday - Thursday
    Pay Rate: $33.47 – $42.68 an hour. Salary is based on qualifications and experience.
    Position Summary: Responsible for ensuring that HIPPA compliant formats and best practices are used for electronic data exchange throughout the organization by monitoring and managing the performance of all systems and monitoring adherence to all related policies and procedures.
    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.
  • Ensures that HIPPA compliant formats and best practices are used for electronic data exchange throughout the organization by monitoring and managing the performance of the Data Warehouse, the Electronic Authorization System, Electronic Claims Systems, Electronic Eligibility and Data Exchange services on the SCPMCS Website and FTP services.
  • Manages and controls all batch inload/outload of data to the EZ-Cap system to ensure accuracy and timeliness.
  • Facilitates the transition from manual to electronic communications to achieve greater participation by providers. Works with the Network Management Department to obtain provider participation.
  • Manages all EDI processing and server data related to all data exchange systems to achieve conformance with policies and procedures. Manages user registration for HealthPlan portals and end user access training.
  • Recommends data formats and ensures that data content and transmission methods are compliant with HIPAA standards. Recommends organizational wide policies and procedures for data exchange into and out of the organization, and monitors adherence to those procedures.
  • Participates in regular and temporary teams as assigned by the Director of Information Technology.
  • Coordinates software Vendors, IT Staff, Providers, Health Plans and SCPMCS Departments to create and maintain HIPAA compliant systems and procedures for data exchange.
  • Reports all security, privacy and procedure breaches to the Director of Information Technology immediately.
  • Performs other duties as assigned, including cross training and coverage of the IT Department.
  • Position Qualifications and Requirements: Experience/Specialized Skills::
  • Proven experience managing multiple electronic environments for data exchange with Trading Partners in both batch and interactive environments, internally and externally.
  • Must be familiar with and have experience with EDI X12 Transaction Sets, EDI Mapping Applications and multiple protocols in a medical transaction environment.
  • Must have strong working knowledge of Windows Desktop and Server Administration. Working knowledge of MS Office, Excel and Word, and Adobe Acrobat.
  • Working experience with EZ-Suite (EZ-Cap, EZ-Net) not required by preferred.
  • Proven ability to work with multiple projects with internal personnel and Trading Partners in a professional manner. Excellent interpersonal skills are essential.
  • Must be able to occasionally work evenings and weekends as needed.
  • Education/Course(s) /Training: • Bachelor’s Degree in Information Systems or Business Administration preferred. Network Administration, Desktop Support and Database Administration a plus.
    Licensure/Certification: N/A
    Location: Mira Mesa, San Diego
    Date Posted: January 25, 2024
    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: $42.20 - $51.71 an hour. 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: January 25, 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/Benefit Data Support Specialist

    Department: Finance
    Level: Non-supervisory
    Reports To: Manager Revenue Recovery & Reimbursement
    Private Health Information (PHI): Position requires read/write access to providers and fee schedules. Read only access for authorizations, eligibility, and claims.
    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: Inputs new contracted providers in EZCAP. Updates provider demographics and contract status. Maintains and updates Financial Responsibility Tables, Benefit Rules and EZCAP Service Code dictionary with CPT/HCPCS code additions/deletions. Maintains monthly OIG, SAM, Opt-Out Provider and Preclusion Reports.
    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.
  • Update and maintain Financial Responsibility Tables, Benefit Rules, Benefit Matrix and EZCAP Service Code dictionary with CPT/HCPCS code additions/deletions.
  • Update provider address, tax ID, billing address and other demographic changes as notified by either Medical Management or Network Management. Updates provider status (i.e. termination of provider or change in status from contracted to non-contracted) – creating new profiles when appropriate.
  • Inputs new contracted provider/vendor data from Network Contract Summaries. Creates provider and vendor profiles with regard to historical information in order to avoid conflicts and/or discrepancies. Assigns fee schedule based on contract and direction from Reimbursement & Revenue Recovery Analyst.
  • Compares and researches monthly OIG, SAM, Opt-Out Providers and Preclusion Reports with providers in EZCAP database. Maintains monthly spreadsheets and distributes to appropriate staff.
  • Research and update failed fax reports and return provider mail.
  • Adds MIPS % to provider files. Reviews daily check runs to ensure correct MIPS % is being applied.
  • Supports Provider Data Specialist with EDI Rejects and back-up coverage.
  • Completes daily EDI log once EZNET batches are uploaded.
  • Updates and maintains EZCAP ICD 10 dictionary.
  • Other duties as assigned.
  • Position Qualifications and Requirements:
  • Minimum 2 years of managed care experience in the area of claims payment and provider compensation.
  • Analytical and provider demographic research skills required.
  • Proven accuracy and detail oriented.
  • Ability to work independently.
  • Working knowledge of CPT/HCPCS, ICD 10 and modifier codes, including impact on benefits and claims reimbursement.
  • Education/Course(s) /Training: High School Diploma
    Licensure/Certification: N/A
    Location: Mira Mesa, San Diego
    Date Posted: January 29, 2024
    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 and write" access to member appeals/grievances, "read only" access to claims and eligibility.
    Job Classification: Non-Exempt
    Job Type: Full time - Four-Day 10 hour days, Monday - Thursday
    Pay Rate: $19.69 - $24.12 an hour. Salary is based on qualifications and experience.
    Position Summary: Provides internal and external health plan notification of provider adds, terms and changes. Completes intake form and requests appropriate medical records for member complaints and provider appeals.
    Essential Job Functions:
  • Completes intake form accurately for each complaint or appeal received from members or providers. Requests 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.
  • Position Qualifications and Requirements:
  • Prior managed care experience with a medical group or health plan.
  • Customer service skills with health plan members or providers.
  • Proficient with computer, Microsoft Windows environment, database management.
  • Education/Course(s) /Training: Associate Degree
    Licensure/Certification: N/A
    Location: Mira Mesa, San Diego
    Date Posted: January 25, 2024
    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: 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: $17.90 - $21.92 an hour. 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. Monitors pended referral requests for turnaround time compliance.
    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.
  • Attaches copy of pre-service denial letter to denied referral with supporting documentation. Makes copy for the health plan, files alphabetically with denial files.
  • Notifies requesting physician by telephone or fax within four hours of all urgent request decisions.
  • Separates and distributes faxed referral requests at a minimum of five times per day, to appropriate team member.
  • Position Qualifications and Requirements: Experience/Specialized Skills: Knowledge of medical terminology, ICD and CPT coding. 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 25, 2024
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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