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.

Posted on October 1, 2018

Provider Relations Manager

Full Time

Brief job description:

The Provider Relations Manager oversees and coordinates operations in the Provider Relations Department to ensure development and maintenance of positive working relationships with all partners, by collaborating on complex organizational initiatives across the integrated delivery system. Provider Relations Manager acts as a key liaison between CPMG, its primary care physician network and partner organizations, including but not limited to Rady Children’s Health Network “RCHN” and Rady Children’s Hospital “RCHSD”.

Essential Responsibilities:

  • Management of Provider Relations staff including HR issues, performance management, coaching and mentoring.
  • Conduct weekly team meetings, creating agenda, discussion topics and focus.
  • Continuously monitor departmental needs & implement necessary changes re: adequate staffing, education, training opportunities, and team building.
  • 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.
  • Manage provider related issues, grievances and concerns of a complex and politically charged 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.
  • Crafts communications, letters/notifications, reports and training materials with a high level of quality and professionalism.
  • Analyze reports to identify and forecast office-specific needs, including but not limited to, performance data, claims submission, ER visits and PMPY.
  • Encourage and track participation in CPMG events, programs & initiatives.
  • Monitor, validate and ensure accuracy of CPMG physician data on all health plan rosters and directories.
  • Manage physician and ancillary provider network to include compliance management and regional gap analysis.
  • Assist with provider contracting, to include full contracts, amendments and letters of agreement.
  • Receive and respond to provider requests for contracts and inclusion in CPMG network.
  • Update and maintain information on all Provider Relations activities documents to include the CPMG Provider Manual, website, etc.
  • Prioritize competing requirements/projects, providing feedback to senior management when appropriate.
  • Act as a technical expert to internal CPMG staff, cross-departmental staff and all affiliated partners.
  • Complete special projects.

Minimum Job Qualifications (education, experience, certification, skills, etc):

  • Bachelor of Arts degree, and  three (3) years direct experience in managed care, with at least 2 years of experience in Provider Relations functions, within an IPA/Medical Group or health plan.
  • Experience with HMO health plan / managed care operations or an equivalent combination of education and related experience.
  • Management experience is required.
Posted on August 24, 2018

Customer Service Manager

Full Time

Brief job description:

Under the supervision of the Associate Director, Member Services & UM Operations, the Customer Service Manager oversees and coordinates operations in the Customer Service Department and ensures consistent quality service in both authorization processing and in completion of phone calls.

Essential Responsibilities:

  • Management of Customer Service staff including HR issues, performance management, coaching and mentoring.
  • Continuously monitor departmental needs & implement necessary changes re: adequate staffing, education, training opportunities, and team building.
  • Conduct weekly team meetings, creating agenda, discussion topics and focus.
  • Administration of Customer Service software systems: IDM to include troubleshooting, training, etc.
  • Create & analyze employee productivity statistical reports; identify trends, problems and any resolution needed.
  • Maintains current, and creates/revises policies, procedures and training tools regarding Customer Service activities, in compliance with new and updated regulations that accurately reflect CPMG processes.
  • Handle member or provider escalated issues, which includes reviewing, researching and collecting information from appropriate entity (claims, contracting, medical director, etc.)
  • Works collaboratively with the Associate Director and UM clinical team to identify and implement process improvement initiatives.
  • Communicates with key health plan contacts to ensure resolution of claims, benefits, and authorization disputes, as well as problem solving for other identified issues
  • Management of the inbound call center for members and providers, including regular monitoring for quality assurance.
  • Management of Electronic Utilization Management (UM) processes.
  • Management of Rady Children’s MSO Customer Service processes.
  • Management of Rady Children’s MSO customer service supervisor.
Posted on May 16, 2018

Provider Relations Representative

Full Time

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.

Essential Responsibilities:

  • 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.

Minimum Job Qualifications (education, experience, certification, skills, etc):

  • 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.)

“Dr. Barbadillo was my doctor when I was a baby and now that I have a baby she is her doctor. I love her clinic, it’s always neat and clean. Just wanted to say thank you!”

– Anonymous