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Career Opportunities

 


SOUTHERN CALIFORNIA PHYSICIANS MANAGED CARE SERVICES
CURRENT CAREER OPENINGS (As of October 21, 2020)


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:

Administrative Assistant

Department: Network Management
Level: Non-supervisory
Reports To: Director, Network Management
Private Health Information (PHI): Position requires "read only" access to member authorizations and read and write access to member 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: Provides administrative support to the Senior Team by performing a variety of functions including, but not limited to, arranging internal and external meetings/conferences; answering the telephone and taking messages; assisting callers and visitors; drafting presentations; generating reports, rosters and other communications such as contract documents, minutes, forms, directories, correspondence, policies and other projects/duties as assigned.
Essential Job Functions:
  • Telephone/Messages - Answers the telephone on behalf of the Executive Staff in a courteous and professional manner, accurately takes messages and /or refers the caller to the appropriate staff person.
  • Arranging meetings/conferences -Makes appointments, and processes conference registrations as requested. Communicates and confirms meetings with the parties involved in their preferred format. Coordinates the internal conference room availability, catering, set-up and break-down. Participates in meetings as needed.
  • Contract Preparation/Tracking/Distribution - under the supervision of the Director of Network Management, prepares appropriate documents including rates, language and amendments using standard templates. Tracks the contracting process from inception through execution. Summarizes and distributes executed contracts to internal departments following contract guidelines. Negotiates and prepares ad hoc agreements.
  • Record keeping - Maintains logs, files, and generates reports/rosters as requested. Assists with data maintenance required to generate accurate reports/rosters. Participates in Contact Wise development.
  • Correspondence -Drafts and/or types correspondence as requested. This includes letters, mail merges, minutes, forms, policies. Drafts PowerPoint presentations modifies Provider Manuals and supports other marketing activities as requested. Follows company formats consistently and ensures accurate information, appropriate tone and language is used. Copies, faxes, and mails information timely and accurately as requested.
  • Files - Maintains executive and provider files efficiently and accurately.
  • Performs other duties as assigned.
  • Position Qualifications and Requirements:
  • Previous assistant/administrative experience supporting an executive/director in a healthcare setting preferred.
  • Advanced knowledge in MS Office and Outlook; and experience with word processing, creating fonts, spreadsheets, and presentations.
  • Knowledge and experience in office practices, procedures and equipment.
  • Ability to effectively organize, prioritize, and multi-task with strong attention to detail.
  • Excellent interpersonal skills in effectively communicating with individuals, in person and by telephone, in a courteous and professional manner.
  • Excellent writing skills.
  • Demonstrated ability to exercise strict confidentiality in all matters.
  • Demonstrated professional office demeanor.
  • Education/Course(s) /Training: High school diploma required.
    Office related education/courses preferred. Bachelor's Degree preferred.
    Licensure/Certification: N/A
    Location: Mira Mesa, San Diego
    Date Posted: October 21, 2020
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Claims Review Nurse

    Department: Medical Management
    Level: Non-supervisory
    Reports To: Director, Medical Management
    Private Health Information (PHI): Position requires "read only" access to member authorizations and read and write access to member 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 claims for medical appropriateness for payment. Reviews contracted Medical Group’s provider claims appeals for medical necessity, authorization requirements, contractual requirements, benefit determination and Medicare payment rules. Reviews the medical documentation submitted with the claim appeal to make an informed decision, recommending denial or payment of the claim. Processes all claims review within timeframes. Documents in the authorization system on the applicable authorization and/or the claims notes.
    Essential Job Functions:
  • Reviews claims for medical appropriateness for payment, including provider contract status, referral source, coding compliance, medical group’s financial responsibilities, benefit interpretation, coverage policy, etc.
  • Claims review completed within established timeframes to maintain compliance with legislative and delegation standards.
  • Researches in depth genetic testing claims from non-contracted laboratories regarding appropriateness for coverage. Makes recommendation to Senior Team for approval or denial.
  • Reviews claims related ad hoc reports for medical appropriateness, chemotherapy documentation, OB claims, over under-utilization trends and other reports as determined by management.
  • Perform other duties as assigned.
  • Position Qualifications and Requirements:
  • Experience/Specialized Skills: Prior experience in claims review and/or utilization management in a managed care environment. Proficient with computer, Microsoft windows environment.
  • Education/Course(s) /Training: Registered Nurse
    Licensure/Certification: Unrestricted, active California RN License.
    Location: Mira Mesa, San Diego
    Date Posted: October 21, 2020
    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: 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 a plus
  • Education/Course(s) /Training: High School Diploma
    Licensure/Certification: N/A
    Location: Mira Mesa, San Diego
    Date Posted: October 21, 2020
    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: October 21, 2020
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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    Utilization Management Representative

    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: Performs data entry of referral requests. Contacts Health Plans for medical policies or benefit interpretations. Contacts physician offices to obtain additional clinical information.
    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.
  • Works Status 7 (Requested) Referrals daily, checking benefits as applicable, changing status to N (Nurse Review) to facilitate timely referral processing.
  • Sorts and distributes faxed referral images into designated employee folders on a rotating shared sorting schedule. Attaches electronic faxed medical record images to EZ-Cap authorization.
  • Attaches copy of pre-service denial letter to denied referral with supporting documentation.
  • Notifies requesting physician by telephone or fax within four hours of all urgent request decisions, if directed by Outpatient Case Manager.
  • Position Qualifications and Requirements:
  • Experience/Specialized Skills:
        o Knowledge of medical terminology, ICD and CPT coding.
        o Proficient with computer, Microsoft Windows environment.
  • Education/Course(s) /Training: High School Diploma
    Licensure/Certification: N/A
    Location: Mira Mesa, San Diego
    Date Posted: October 21, 2020
    To apply for this position, click here to complete the employment application and submit it to jobs@scpmcs.org


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