SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES CURRENT CAREER OPENINGS (As of November 22, 2021)

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:

• Inpatient/SNF Case Manager
• Outpatient Case Manager (RN)

Inpatient/SNF 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:	Full time - Four-Day 10 hour days, Monday - Thursday
Pay Rate:	Salary is based on qualifications and experience
Position Summary:	Reviews Medical Group’s inpatients, rehab, long term acute (LTAC), and skilled nursing admissions on a concurrent basis for medical necessity. Reviews ongoing stays for continuing care criteria being met. Coordinates discharge plans with the facility’s case managers for timely discharge.
Essential Job Functions:	Reviews the Medical Group's inpatients on a concurrent basis for medical ecessity. 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 daily. Utilizes hospital medical record systems for on-line information. Reviews all long-term acute care 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 rehab level of care and senior skilled nursing members prior to discharge. Issues exhaustion of benefits letters. Issues authorizations for post-discharge services. Contacts out of network facilities for clinical information for any medical Group's member admitted to the facility. 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. Issues hospital denial for members not meeting acute level of care.
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. Must have reliable transportation, valid California Driver's License and proof of insurance.
Location:	Mira Mesa, San Diego
Date Posted:	November 22, 2021
	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:	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 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. Must have reliable transportation, valid California Driver's License and proof of insurance.
Location:	Mira Mesa, San Diego
Date Posted:	November 22, 2021
	To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org

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