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Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of January 26, 2023)


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:

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: January 26, 2023
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Inpatient Case Manager

    Department: Medical Management
    Level: Non-supervisory
    Reports To: Manager, Health Services
    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: Part time
    Pay Rate: Salary is based on qualifications and experience
    Position Summary: Reviews Medical Group's inpatients on a concurrent basis for medical necessity. Coordinates discharge plans with the hospital or skilled facility's case manager for timely discharge. Reviews all skilled nursing admissions for appropriateness of admission and continuing care. Issues Notice of Medicare Non-Coverage for all senior skilled nursing discharges.
    Essential Job Functions:
  • Reviews the Medical Group's inpatients on a concurrent basis for medical necessity. 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 on a daily basis.
  • Reviews all transitional care unit 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 transitional care and senior skilled nursing members prior to discharge or at exhaustion of benefits.
  • Contacts out of network facilities for clinical information for any Medical Group's member admitted to the facility. Informs member's PCP of admission. 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.
  • 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: January 26, 2023
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Performance Improvement Manager

    Department: Network Management
    Level: Supervisory
    Reports To: Director, Network Management
    Private Health Information (PHI): Position requires access to PHI, including "read only" access to eligibility, claims and authorizations. "Write" access to member notes and provider notes.
    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: Provide leadership and operational management for quality and risk programs across the provider network. Supervises the daily activities of the performance team. Develops and implements quality improvement initiatives. Collaborates with internal departments and health plans to ensure compliance with IHA, HEDIS and CMS Stars initiatives. Responsible for annual quality data reporting and the audit process. Oversees the annual assessment program to ensure accurate documentation.
    Essential Job Functions:
  • Reporting – Monitor IPA performance and staff productivity. Analyze data to measure program effectiveness.
  • Programs – Develop and monitor initiatives for ongoing IPA improvement. Create tools and materials for training and performance monitoring.
  • Client Relations – Works with the Director of Network Management to maintain positive and productive relationships between department staff, health plans, providers and members. Works with Provider Relations team to communicate with physicians and their staff. Meet with physicians as needed.
  • Staff Supervision – Supervises the daily activities of the performance staff, employee work schedules and work assignment to ensure effective business operations. Takes appropriate corrective action when required to improve employee performance in accordance with policy. Participates in the interviewing and hiring of new staff. Provides staff training as required.
  • Represents the MSO in state/regional meetings and conferences specific to quality. Including but not limited to IHA, health plans, IPA meetings, vendor user conferences.
  • Performs other duties as assigned.
  • Position Qualifications and Requirements:
  • Prior supervisory experience managing diverse areas of responsibility. Minimum of 3 years of operations experience in a health plan, MSO or medical group environment and have a working knowledge of managed care principles.
  • Prior Quality Improvement experience. Knowledge of regulatory requirements related to quality programs including NCQA’s HEDIS, Medicare STARS and the Integrated Healthcare Assoc. AMP program.
  • Strong customer service and professional communication skills, both written and verbal, required.
  • Excellent organizational and time management skills. Ability to work on multiple complex projects simultaneously.
  • Advanced knowledge of Microsoft Word, Excel, email and intermediate knowledge of PowerPoint, Access and other applications/information system pertinent to managing data and conducting training sessions. Experience in data analysis.
  • Familiar with claims processes, CPT, ICD-10 and HCPCS coding desired. Certificate in coding is a plus
  • Education/Course(s) /Training: Bachelor’s Degree in health care administration, public health, nursing, or other related field or equivalent work experience required.
    Licensure/Certification: Reliable transportation, a valid CA Driver’s License, and current car insurance meeting CA standards.
    Location: Mira Mesa, San Diego
    Date Posted: January 26, 2023
    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: January 26, 2023
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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