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.
Posted on May 16, 2018
Provider Relations Representative
Brief job description:
The ideal candidate will act 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.
- High school degree or equivalent education/Bachelor’s degree preferred
- 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
- Solid Knowledge of Excel (Pivot tables, macros, VLOOKUP etc.)
- 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.
- Receives, researches, and responds to unique and/or complex inquiries from providers and senior leadership with minimal supervision.
- Manages provider related issues, grievances and concerns of a complex nature, with a high level of professionalism.
- Prepares 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.
Customer Service Representative
Brief job description:
This position promotes favorable relationships with members, providers, and health plans through the prompt, accurate and courteous resolution of issues; receives and responds to customer inquiries (telephone, written and electronic) that may pertain to all phases of CPMG operations including authorizations, claims inquiries and provider network access; documents all customer contacts, including resolution or action taken to refer question to proper entity; and assists and educates member families with navigation of HMO processes. The position will also include: Data entry/processing of authorization requests, including verification of benefits; researching of authorization history and provider notes; using correct CPT/ICD10 codes; providing referrals within the CPMG network; working collaboratively with all professional entities relating to CPMG business; and assisting colleagues as necessary on special projects with time-critical deadlines.
Minimum job qualifications (education, experience, certification, skills, etc):
- High school degree or equivalent education with computer keyboarding skills.
- Three (3) years experience working with Health Plans/Health Care.
- Excellent verbal and written language skills to answer customer concerns in simple, understandable language.
- Previous customer service experience in a physician office, hospital, or other healthcare setting.
- The ability to work both independently and as part of a team, maintain confidentiality and exhibit a professional demeanor.
- Knowledge of health plan benefits, claims, ICD-10/CPT coding.