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 REVIEW COORDINATOR

Department: Utilization Management (UM)

Reports To: UM/QI Manager and Compliance Liaison

FLSA status: Exempt

Under the supervision of the UM/QI Manager and Compliance Liaison, the Utilization Review Coordinator reviews medical services requested for prior authorization, concurrent authorization, or retro authorization, and to authorize and/or redirect to appropriate care based on the benefits of the member along with the clinical information presented.

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 responsibilities may be assigned.

  • Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of all requested services, in both the inpatient and ambulatory setting.
  • Performs concurrent reviews for patients to ensure the lengths of stay are medically justified and are so documented.
  • Establishes the specific coverage and benefit plans of individual members when reviewing authorization requests.
  • Refers to the medical director all cases that do not appear to meet coverage criteria, and/or are not part of the member’s benefit package.
  • Assists in the coordination of referrals as needed, including, but not limited to, redirection to a network provider, and additional funding sources beyond insurance benefits.
  • Communicates, as needed, with both providers and families regarding UM decisions, and other elements pertaining to authorization requests.
  • Communicates with other members of the UM team to ensure timely authorizations, consistent UM processes, and appropriate referrals to case management and/or disease management and community programs.

SUPERVISORY RESPONSIBILITIES
No supervisory responsibilities.

INTERACTION
Utilization Review Coordinator continually interacts with CPMG management, other members of the UM team and the public.

EDUCATION AND EXPERIENCE
A minimum of three years clinical experience, with pediatric background preferred. At least 2 years managed care experience, with utilization or case management a plus.

CERTIFICATES, LICENSES, REGISTRATIONS
Must possess a current unrestricted California RN license. Case management certification preferred.

QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

KNOWLEDGE/SKILLS/ABILITIES:
Technical

  • Knowledge of common medical insurance operations
  • Strong mathematical and reasoning skills

Communication

  • Excellent communication skills both verbal and written.
  • Ability to maintain composure when confronted with fast-paced and stressful situations.
  • Ability to read, write, interpret and explain simple to complex information.
  • Ability to maintain composure when confronted with fast-paced and stressful situations.

Organization

  • Excellent organizational and multi-tasking skills
  • Ability to follow-through to completion on tasks and responsibilities
  • Ability to work independently and with a high degree of accuracy
  • Strong detail orientation.
  • Ability to work under deadlines, while maintaining efficiency and accuracy.

Reasoning and Judgment

  • Strong analytical and problem solving skills.
  • Ability to use good judgment and demonstrate discretion in the handling of confidential and or sensitive information.
  • Ability to perform non-routine tasks.
  • Ability to understand and act upon verbal and written instructions, prioritize and complete multiple tasks.
  • Ability to analyze, compile and prepare data.

Teamwork

  • Ability to approach others in a tactful manner, react well under pressure and follow through on commitments.
  • Proven ability to deal positively with a wide range of people and personalities and handle tense situations in a diplomatic fashion.
  • Ability to work effectively as a team member; demonstrating cooperation and mutual support of others to accomplish a common goal.

Resources

  • Ability to operate office equipment including PC computers, photocopiers, fax machines, calculators, and multi-line phone systems.
  • Proficient in the Microsoft Office Suite.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The work environment is a typical office setting.  The noise level in the work environment is usually moderate and it is well lit, temperature controlled ventilated environment.

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.


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