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Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of June 10, 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:

Claims Auditor

Department: Claims
Level: Non-Supervisory
Reports To: Manager, Claims & Eligibility
Private Health Information (PHI): Position requires read and write access to member claims and read only access to member eligibility and authorizations.
Job Classification: Non-Exempt
Job Type: Full time - Four-Day 10 hour days, Monday - Thursday
Pay Rate: $21.66 - $26.53 an hour. Salary is based on qualifications and experience.
Position Summary: These duties are split over four Auditor positions. Claims Auditors are responsible for the auditing of provider disputes, member denial letter requests, and daily prelag reports. Responsible for ensuring provider dispute and member denial letters are accurately handled. Responsible for notifying management of any compliance concerns with timeliness of claims payments. Reviewing and resolving HPIs and member OOP.

This position is primary focus on reviewing member out of pocket max notices and process corrections to member OOP as needed. Reviewing & processing member copay corrections. Position will also focus on check run reviews, including working all pre/post check run audit reports to ensure claims payments are accurate.
Essential Job Functions:
  • Reviews provider disputes and letters for assigned region(s) on a daily basis for accuracy to ensure timeliness of acknowledgement and resolution. Log errors for use in annual performance review. Reports errors to Claims Manager monthly.
  • Monitors pre-lag reports for assigned region(s) on a daily basis for compliance with health plan mandated turnaround times.
  • Responsible for ensuring that Virtual Examiner edits are run each day and that the edits are accurately applied according to SCPMCS and Client guidelines.
  • Reviews various check run reports.
  • Reviews and processes Fax Backs.
  • Works claim notes sent via email from BN team.
  • Reviews Auditor pre-lag reports and send compliance issues to Lead Claim Auditor.
  • Reviews and processes various daily/weekly reports for assigned IPA.
  • Acts as back up for fellow Claims Auditor.
  • Position Qualifications and Requirements:
  • 3 years of experience in managed care claims processing.
  • Knowledge of HCFA, Medi-Cal and HMO claims payment regulations.
  • Claims auditing experience.
  • Ability to communicate effectively, verbally and in written form.
  • Ability to achieve collaborative problem solving among Claims and Eligibility Staff and with other SCPMCS departments and Health Plans.
  • Competent in the use of computer programs, especially Microsoft Word and Excel.
  • Education/Course(s) /Training: High School Diploma required.
    Licensure/Certification: N/A
    Location: Mira Mesa, San Diego
    Date Posted: June 10, 2024
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    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: June 10, 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: June 10, 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: Director 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: June 10, 2024
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Director, Medical Management

    Department: Medical Management
    Level: Senior Team
    Reports To: Chief Executive Officer
    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: $63.49 - $83.18 an hour. Salary is based on qualifications and experience.
    Position Summary: Ensure quality health care services are provided to our clients and members, providing oversight to the quality management, utilization management and credentialing functions of the organization.
    Essential Job Functions:
  • Develop, implement and update medical management programs in the areas of utilization management, case management, quality improvement, credentialing and member/provider appeals to remain current with health care trends and legislative requirements.
  • Direct responsibility for the department’s operations for quality management including credentialing, member and provider appeals, utilization management including inpatient, outpatient and high risk case management and maintaining positive relationships with the Medical Directors, Health Plan Representatives, Senior Team and Clients.
  • Responsible for maintaining Client’s delegated status for utilization management and credentialing with all contracted health plans. Review and assist in the negotiations of health plan delegation agreements on an annual basis.
  • Develop, review and revise departmental policies and procedures at least annually to ensure current legislative and regulatory compliance.
  • Ensure staff recruitment and selection process and performance evaluations are completed in a fair and consistent manner.
  • Supports vision of the Senior Team. Actively participates in developing solutions to strategic issues.
  • Works collaboratively with other Senior Team members and SCPMCS department managers for high quality MSO services.
  • Position Qualifications and Requirements: Experience/Specialized Skills::
  • Three to five years experience at a senior level in medical management in a managed care, health plan, or medical group setting.
  • Education/Course(s) /Training: • Bachelor of Science Degree, Master’s Level preferred.
    Licensure/Certification: Current unrestricted California Registered Nurse licensure. Reliable transportation, valid California Driver’s license and proof of insurance.
    Location: Mira Mesa, San Diego
    Date Posted: June 10, 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: June 10, 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: June 10, 2024
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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