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.

RN Case Manager
Full Time

CPMG has an exciting opportunity for a dedicated and caring professional to join our team as a RN Case Manager. This team member will work with all members of the health care team to coordinate the delivery of care through assessment, planning, facilitation, and patient advocacy to ensure cost-effective quality outcomes of care. Additionally, this position will collaborate with all members of the health care team to ensure optimal outcomes are reached while appropriate utilization occurs.

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

  • Registered Nurse with current unrestricted California License.
  • Minimum of three years clinical experience, with pediatric background preferred.
  • At least two years managed care experience with case management.
  • Good computer skills with knowledge of Excel, Word, PowerPoint, Outlook, and Access
  • Excellent verbal and written communication skills
  • Strong analytical and problem solving skills.

For consideration please email resume and cover letter including salary requirements. Children’s Physician Medical Group offers the full scope of benefits, a great compensation package and opportunities for professional growth. EOE. For more information please visit our website at https://cpmgsandiego.com

Customer Service Representative

Full Time

The Customer Service Representative promotes favorable relationships with members, providers, and health plans through the prompt, accurate and courteous resolution of issues; receives and respond 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; 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, research of authorization history, provider notes, use of correct CPT/ICD9 codes; providing referrals within 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-9/CPT coding.

 

Administrative Specialist

Full Time

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 Associate Director, Member Services & UM Operations, but will also assist with projects or activities of related departments, including Quality Improvement, Provider Relations, and Customer Service. The UM 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 Responsibilities:

  • Maintains all Utilization Management letter templates, based on health plan requirements, including letter templates for multiple health plans, in multiple languages, which are strictly monitored by regulatory agencies.
  • Compiles data and independently composes reports and correspondence involving an understanding of operating unit programs, policies, and procedures.
  • Responds to health plan correspondence and coordinates production of reports or requests for data in response to health plan 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 Associate Director, Member Services & UM Operations, and the Director, Network Operations.
  • Assists with committee meetings, including preparation of committee meeting materials, compiling meeting agendas, printing of materials, and preparation of meeting minutes.
  • Performs related duties as assigned.

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

  • High school or equivalent required. Some college preferred.
  • Minimum of three (3) years of administrative support experience. Administrative healthcare experience a plus.

 

For consideration please email resume and cover letter, including salary requirements. Children’s Physician Medical Group offers the full scope of benefits, a great compensation package and opportunities for professional growth. EOE. For more information please visit our website at https://cpmgsandiego.com