SCPMCS - About SCPMCS - Career Opportunities

SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES CURRENT CAREER OPENINGS (As of February 17, 2022)

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:

HMO Benefit Analyst

Department:	Finance
Level:	Non-supervisory
Reports To:	Manager, Revenue Recovery & Reimbursement
Private Health Information (PHI):	Position requires "read only" access 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:	Accurately maintains and updates benefit tables to assure current and accurate information is loaded.
Essential Job Functions:	Obtains Summary of Benefits and/or EOC(s) from Health Plan Provider Portals, Health Plan Representatives and monthly data files to forward to Calibrated Healthcare for benefit builds. Reviews and accurately interprets HMO benefit and inputs in the EZCAP Benefit Matrix modules. Maintains and updates existing tables to ensure current and accurate information is loaded. Consults with Health Plan Representatives, whenever necessary, for plan benefit interpretation including co-payments and financial responsibility. Resolves daily claim issues with respect to unusual or missing co-payment, non-covered services and financial responsibility questions. Ad hoc addition of new benefit tables for newly enrolled members per daily eligibility requests. Annual updating of CPT and HCPCS codes (deletions/additions) to Benefit Rules and Advanced Benefit Rules. Other duties as assigned.
Position Qualifications and Requirements:	Minimum three years' experience in Managed Care with emphasis on HMO Health Plan benefits, financial matrices, and claims processing. Experience with Microsoft Office preferred. Good verbal communication and interpersonal skills. Ability to work independently and must be a self-starter
Education/Course(s) /Training:	High School Diploma
Licensure/Certification:	N/A
Location:	Mira Mesa, San Diego
Date Posted:	February 17, 2022
	To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org

Medical Assistant - Performance Improvement (Temp to Hire)

Department:	Network Management
Level:	Non-supervisory
Reports To:	Manager, Performance Improvement
Private Health Information (PHI):	Position requires "read only" access 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:	Supports performance improvement in the Network Management Department by assisting in the design and execution of targeted data mining projects. Reconciles data with select health plans and conducts chart reviews to satisfy HEDIS specifications.
Essential Job Functions:	Data Gathering - Work with Provider Relations Representatives as needed to gain access to the appropriate office contacts for data mining. Scheduling on-site visits at provider offices to review paper and electronic medical records utilizing HEDIS specifications. Meet or exceed accuracy standard of 95%. File Maintenance / Data Tracking / Research – Prepare reports with targeted health plans including supplemental data, gap analysis and other ad hoc activities to monitor quality data. Review data sources from internal and external systems to identify quality data. Member Outreach - Where indicated, contact members to discuss needed screenings. Meetings - Represent MSO in meetings with providers and the project health plans to reconcile data listings. Performs other duties as assigned.
Position Qualifications and Requirements:	Minimum two years experience working in a clinical setting maintaining documentation. Understanding of provider office operations. Proficiency with multiple EHR systems. Ability to read medical records. Strong customer service and professional communication skills, both written and verbal, required. Basic knowledge of HEDIS measures. Excellent organizational and time management skills and ability to handle multiple tasks. Proficient in Outlook, Excel, and Word. Ability to learn company-specific software programs (Cozeva). Demonstrated ability to handle confidential or sensitive issues in a responsible manner.
Education/Course(s) /Training:	Medical Assistant (MA) Certification
Licensure/Certification:	Reliable transportation, a valid CA Driver's License, and current car insurance meeting CA standards.
Location:	Mira Mesa, San Diego
Date Posted:	February 17, 2022
	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:	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:	February 17, 2022
	To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org

Production & Eligibility Assistant

Department:	Claims & Eligibility
Level:	Non-supervisory
Reports To:	Production & Eligibility Supervisor
Private Health Information (PHI):	Position requires "read only" access to member claims; read and write access to 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:	Processes daily EDI files through EZNet. Reviews daily eligibility requests and updates EZCap accordingly. Handles daily mail room tasks including processing incoming and outgoing mail.
Essential Job Functions: Eligibility	Researches the EZCap system and health plan eligibility information via health plan website or telephone for eligibility verifications. Updates EZCap accordingly
Essential Job Functions: Production	Uploads files from clearinghouses and direct submitters into EZ-Net on a daily basis. Logs each file on monthly In-load Log spreadsheet. Processes and Posts claims. Deletes batches when all processing is complete Generates and downloads acknowledgement and reject files Re-loads original claim for PDRs and attaches PDR DCN to newly created claim. Notifies analysts of any claims that could not be data captured and requires manual entry Sorts and operates folding machine for all outgoing letters and checks Compiles misdirected claims. Prints misdirected claims and mails them to appropriate health plan Applies postage to all outgoing mail Sorts and distributes incoming mail Distributes incoming fax emails Keeps mailroom clean and stocked. Refills the copier and fax machine with paper as required
Position Qualifications and Requirements:	High School or equivalent (preferred) US work authorization No managed care experience needed (will train accordingly) Computer experience required
Education/Course(s) /Training:	High School Diploma
Licensure/Certification:	N/A
Location:	Mira Mesa, San Diego
Date Posted:	February 17, 2022
	To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org