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.

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.

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.