SCPMCS - About SCPMCS - Career Opportunities

SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES CURRENT CAREER OPENINGS (As of September 21, 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:

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 21, 2023
	To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org

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.
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 preferred. 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:	September 21, 2023
	To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org

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:	September 21, 2023
	To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org

Utilization Management Representative (Temporary)

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:	September 21, 2023
	To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org