Building The Right Team.

Children’s Physicians Medical Group (CPMG) is a pediatric-only Independent Physicians Association (IPA), associated with Rady Children’s Hospital – San Diego. Its provider network includes nearly 200 primary care pediatricians and 240 pediatric sub-specialists. These providers, in conjunction with Rady Children’s Hospital, have formed an Integrated Delivery System (IDS) known as Rady Children’s Health Network (RCHN). Currently, almost 72,000 children are enrolled in CPMG through eight managed care Health Plan contracts and two Medi-Cal contracts. Additionally, CPMG and its network partners provide MSO services to 400,000 other patients and their providers in San Diego, Southern Riverside, and Orange County.

TO BE CONSIDERED FOR ANY OF THE FOLLOWING OPPORTUNITIES, PLEASE SUBMIT A LETTER OF INTEREST AND RESUME TO HUMAN RESOURCES AT cpmghr@rchsd.org.

UTILIZATION MANAGEMENT (UM) OPERATIONS TRAINER

Full Time

Under the supervision of the UM Operations Manager, the UM Operations Trainer’s primary job function is to support Utilization Management operations by training non-clinical staff on how to successfully perform any non-clinical tasks. This includes, but is not limited to, initial authorization processing (data entry, eligibility verification, benefits verification, and requesting required supporting documents from submitting provider offices), answering the phone (including all calls regarding authorization processing, claims related phone calls, and any other calls received via the call center lines), and appropriately processing required UM notifications (letters, faxes, etc.). The UM Operations Trainer is responsible for practicing all of the functions they perform training on as part of their standard job function.

ESSENTIAL DUTIES AND RESPONSIBILITIES
The following statements are intended to describe the general nature and level of work being performed by an individual assigned to this job. Other duties may be assigned.

  • Training Responsibilities –
    • Development of training courses/programs as necessary. This includes training content, presentations, handouts, and testing to assess understanding.
    • Maintenance and updates to current training materials, with leadership approval.
    • Provide comprehensive training to all new UM Operations Department staff.
    • Track, document,and complete required annual trainings under UM regulations (i.e., Cultural and Linguistic Training, Adverse Events Training, etc.)
    • Provide feedback to leadership regarding possible updates to processes and procedures based on observations during training processes.
    • Reinforces training provided by leadership and provides supplementary training as needed.
  • Accurately enter information into the authorization software system (EZ-Cap) and ensure timely processing of the authorization requests in compliance with Federal, State, Health Plan, and NCQA standards.
  • Conduct eligibility and benefit verification via the health plan website or outbound phone calls to health plan provider services lines. Document any benefit information in the authorization software system (EZ-Cap).
  • Administratively approve authorization requests based on internal processing guidelines
    and tools.
  • Multitask and prioritize authorization processes and telephonic inquiries to ensure the
    team is able to successfully complete the workload designated to the department.
  • Receive and respond to customer inquiries (telephone, written and electronic) that may
    pertain to all phases of CPMG operations including authorizations, claims, and accessing provider network.
  • Document all customer contacts, including resolution or action taken to refer question to proper entity. Includes tracking member complaints and referral to appropriate entities for grievance procedures as needed.
  • Educate member families on navigation of HMO processes.
  • Assist/educate providers on process for submitting authorization requests, interpretation of denials and appeal process, navigating CPMG website and EZ-Net portal.
  • Support the generation of daily approval and pending letters and dissemination to required entities (member, health plan, provider) in accordance with NCQA/ICE standards and guidelines.
  • Work collaboratively with all professional entities relating to CPMG business. Includes health plans, physician offices, and vendors.
  • Work closely with the clinical UM personnel to ensure appropriate processing of authorization requests, including timely processing to allow for clinical review processes.
  • Assist colleagues as necessary on special projects with time critical deadlines.
  • Adhere to CPMG Policies & Procedures.

Minimum job qualifications (education, experience, certification, skills, etc):

  • Bachelor’s Degree preferred, high school diploma would be considered with sufficient experience. A minimum of 2 years of experience in UM Operations.
  • Experience in the provision of training preferred.
  • Medical Terminology, ICD-10 Codes, CPT Codes, HCPC Codes, Health plan benefits, or claims required.
  • Computer skills required, specifically Excel, EZ-Cap, Word, Outlook, Internet/Web searching, and Epic.

ADMINISTRATIVE SPECIALIST

Full Time

Under the supervision of the Director, UM Operations & Member Services, the Administrative Specialist will provide administrative support regarding operational aspects of Utilization Management requirements. Work shall include extensive computer work in Excel, Word, Outlook, PowerPoint and data entry in other software systems. Will be working primarily with the Director, UM Operations & Member Services, but will also assist with projects or activities of related departments, including Quality Improvement, Provider Relations, UM Operations, and UM Clinical. The Administrative Specialist is expected to have strong computer skills, the ability to communicate in a collaborative and efficient manner, and the ability to effectively prioritize projects and work independently.

ESSENTIAL DUTIES AND RESPONSIBILITIES
The following statements are intended to describe the general nature and level of work being performed by an individual assigned to this job. Other duties may be assigned.

  • Maintains all Utilization Management letter templates based on health plan requirements, includes letter templates for multiple health plans, in multiple languages, which are strictly monitored by regulatory agencies.
  • Responsible for compiling outbound communications required under health plan regulations, including notices to members regarding termination of providers, and notices to providers regarding unused authorization requests.
  • Demonstrates strong professional communication skills while communicating with internal and external customers, including health plan oversight agents, clinical staff, and other health care professionals.
  • Responsible for appropriate tracking, processing, and response to all Grievances and Appeals. Includes communication with health plan representatives, provider offices, and internal clinical staff in an organized and collaborative manner.
  • Performs special projects on a regular basis for a variety of departments and leaders. Must be able to ascertain when various projects would take priority.
  • Assists with organizing and preparing for health plan regulatory audits of Utilization Management processes. Includes review and preparation of audit materials in conjunction with the Director, UM Operations & Member Services.
  • Assists with committee meetings, including preparation of committee meeting materials, compiling meeting agendas, printing of materials, and preparation of meeting minutes.
  • Provides support to clinical team members, including, but not limited to, verification of benefits from the health plan, requesting records from outside offices or organizations, and review of language in outbound communications for clarity and understanding.
  • Performs related duties as assigned.

Minimum job qualifications (education, experience, certification, skills, etc):

  • High School or equivalent required.
  • Bachelor’s Degree preferred.
  • Minimum of three (3) years of experience in a health care related field.

PROVIDER RELATIONS REPRESENTATIVE

Full Time

This position acts as a key liaison between CPMG’s primary care physician network, ancillary providers, health plans, and other partner organizations. The Provider Relations Representative is responsible for the development and maintenance of positive working relationships with all partners, by collaborating on complex organizational initiatives across the integrated delivery system.

ESSENTIAL DUTIES AND RESPONSIBILITIES
The following statements are intended to describe the general nature and level of work being performed by an individual assigned to this job. Other duties may be assigned.

  • Works directly with senior management to create and implement policies/procedures for network of contracted providers in order to further CPMG’s strategic plan.
  • Primarily responsible for education of contracted offices, including physicians, administrators and billing staff, on CPMG/RCHN initiatives, serving as a liaison to CPMG administration.
  • Receive, research, and respond to unique, complex inquiries from providers and senior leadership with minimal supervision.
  • Manage provider related issues, grievances and concerns of a complex nature, with a high level of professionalism.
  • Prepare presentations for committee and/or board meetings relative to Provider Relations initiatives.
  • Acts as a subject matter expert (SME) on the operations of CPMG’s network of providers, including office performance, structure, and nuances.
  • Initiates corrective action plans for contracted providers, including contract and legal review when appropriate.

Minimum job qualifications (education, experience, certification, skills, etc):

  • Bachelor’s degree highly desirable/ minimum high school degree or equivalent education
  • Three (3) years direct experience in managed care, with working knowledge of IPA/Medical Group, health plan / HMO operations, physician office management, or an equivalent combination of education and related experience

UTILIZATION MANAGEMENT (UM) COORDINATOR

Full Time

Under the supervision of the UM Operations Manager, the UM Coordinator’s primary job function is to support Utilization Management operations by performing any non-clinical tasks. This includes, but is not limited to, initial authorization processing (data entry, eligibility verification, benefits verification, and requesting required supporting documents from submitting provider offices), answering the phone (including all calls regarding authorization processing, claims related phone calls, and any other calls received via the call center lines), and appropriately processing required UM notifications (letters, faxes, etc.).

ESSENTIAL DUTIES AND RESPONSIBILITIES
The following statements are intended to describe the general nature and level of work being performed by an individual assigned to this job. Other duties may be assigned.

  • Accurately enter information into the authorization software system (EZ-Cap) and ensure timely processing of the authorization requests in compliance with Federal, State, Health Plan, and NCQA standards.
  • Conduct eligibility and benefit verification via the health plan website or outbound phone calls to health plan provider services lines. Document any benefit information in the authorization software system (EZ-Cap).
  • Administratively approve authorization requests based on internal processing guidelines and tools.
  • Multitask and prioritize authorization processes and telephonic inquiries to ensure the team is able to successfully complete the workload designated to the department.
  • Receive and respond to customer inquiries (telephone, written and electronic) that may pertain to all phases of CPMG operations including authorizations, claims, and accessing provider network.
  • Document all customer contacts, including resolution or action taken to refer question to proper entity. Includes tracking member complaints and referral to appropriate entities for grievance procedures as needed.
  • Educate member families on navigation of HMO processes.
  • Assist/educate providers on process for submitting authorization requests, interpretation of denials and appeal process, navigating CPMG website and EZ-Net portal.
  • Support the generation of daily approval and pending letters and dissemination to
    required entities (member, health plan, provider) in accordance with NCQA/ICE
    standards and guidelines.
  • Work collaboratively with all professional entities relating to CPMG business. Includes
    health plans, physician offices, and vendors.
  • Work closely with the clinical UM personnel to ensure appropriate processing of
    authorization requests, including timely processing to allow for clinical review processes.
  • Assist colleagues as necessary on special projects with time critical deadlines.
  • Adhere to CPMG Policies & Procedures.

Minimum job qualifications (education, experience, certification, skills, etc):

  • High School diploma and previous experience in the health care field, such as hospital, medical group, health insurance, or other Risk Bearing Organization (RBO). Bachelor’s Degree will be considered in lieu of experience.
  • Medical Terminology, ICD-10 Codes, CPT Codes, HCPC Codes, Health plan benefits, or claims preferred.
  • Computer skills a plus, specifically Excel, EZ-Cap, Word, Outlook, Internet/Web searching, and Epic.