사무직 구함

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헬스케어 매니지먼트 회사
• Location:
Buena Park, CA
• Contact:
hrdept@popmso.com

Provider Contracting 

Duties

 Maintain, establish, and develop collaborative relationships with network providers and prospective providers

 Call, communicate, and contact various provider offices to send out and obtain contracts through mail, fax, or 

     in-person

 Research and understand the processes of the MSO and the IPAs including but not limited to claims, 

     utilization management, eligibility, credentialing, and contracting

 Provide support to providers regarding the policies and procedures of the IPA, health plans, and state and 

     federal bodies

 Be involved in new business development projects for the MSO and the IPAs

 Perform initial and re-credentialing duties such as conducting primary source verifications, verifying 

     hospital affiliations, and collecting other necessary documents


Experience and Qualifications

 Experience in healthcare

 College graduate (at least an Associate's or a Bachelor's Degree)

 Excellent and proven interpersonal, verbal, and written communication skills

 Ability to keep schedule; customer service; strong work ethic

 Proficiency with Microsoft Excel/Word

VAbility to cope with conflict, stress, and crisis situations

 Ability to drive and travel out-of-state (more than 50% of the time is field work)

 

Utilization Management (UM) Coordinator

Position Summary

This position works collaboratively with the Case Managers, Claims Department, Credentialing and Contracting Department, and other Medical Management staff. The position requires strong written and communication skills and the ability to interact with Medical Directors, Providers, IPAs, Health Plans, and patients to ensure the delivery of high quality, cost effective healthcare.

Duties and Responsibilities

 Enters data and processes referral authorization requests, to include appropriate coding and quantities

 Answers incoming calls from Providers, IPAs, Medical Groups and other internal and external calls and assists on 

     the queues as needed

 Follow up pending referrals to ensure that they are processed in a timely manner

 Educate providers as needed with the referral and authorizations process

 Verifies member eligibility before processing authorizations

 Identifies non-contracted providers and requests letter of agreements or contracts when needed

 Assist the credentialing and contracting department in obtaining contracts, letter of agreements, and other 

     necessary tasks

 Requests supporting documentation from IPAs/Medical Groups as requested by the Case Managers

 Monitors the turn around time timeframes to ensure timely processing

 Contacts facilities identified by the Case/Care Manager/Director/Medical Director to research any issues 

     (i.e., admissions, discharges)

 Assists the Case Managers in coordinating and arranging services for members.

 Assists the Claims Department

 Responds to variations in daily workload by evaluating task priorities according to department policies and standards.

 Maintains confidentiality of information between and among health care professionals

 Follow companies policies, procedures, and processes

 Other duties as assigned

Qualifications and Skills

 REQUIRED: Must be fluent in English. Strong writing, verbal, grammar, spelling, and punctuation skills

 Bachelor's Degree or Associate's Degree preferred

 Some clinical experience pertaining to utilization management

 Knowledge of CMS, DHS, DMHC, NCQA , and ICE guidelines

 Familiarity with MSOs, IPAs, HMO health plans

 ICD-10 and CPT coding experience

 Proficient computer skills with Microsoft Word, Excel, and Adobe Acrobat (PDF)

 

Medical Claims Processor

Description

 Adjusts and adjudicates multiple lines of business in a timely manner to ensure compliance to departmental 

     and regulatory turn-around time and quality standards

 Reviews claims and makes payment/adjustment determination to ensure all components (i.e. member, 

     provider, authorization, claim, and system) are valid and correct for accurate processing

 Conducts research regarding claim completion and appropriateness; identifies errors and takes necessary actions 

     to resolve claims

 Manages work to meet regulatory guidelines

Responsibilities and Duties

 Review claims and makes payment determination

 Review and evaluates claims for proper and correct information including correct member, provider, 

     authorization, and billing information on which to base payment determination

 Refers to eligibility, authorization, benefit, and pricing information to determine appropriate course of action 

    (i.e. claim reject/denial, request for additional information, etc.)

 Conduct research regarding coordination of benefit issues, fraud and abuse, and third party liability

 Utilizes knowledge of government regulatory policies and procedures to ensure compliance with 

     government regulations including but not limited to CMS, DHMC, DOC, DHS, and requirements of 

     accrediting agencies such as NCQA

 Prepares material for audits and provides assistance to Lead and Supervisor during audit

 Assist with the preparation of materials for audits and provides assistance to Lead and Supervisor during audit

 Work together with Lead and Supervisor for claim reporting requirement

 Review member/provider claims by checking provider service contracts and other supporting claims 

     documentation in accordance with service agreements

 Coordinates payment agreement with providers

 Proactively works to ensure claim review is resolved appropriately

Basic Qualifications

 One (1) year medical claims adjudication experience

 Experience in processing multiple types of medical claims and lines of business required

 Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and 

     devise appropriate courses of action

 Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex 

     or technical information in a manner that others can understand, as well as ability to understand and 

     interpret complex information from others

 Intermediate computer skills - Proficiency with Microsoft Word and Excel with the ability to navigate a 

     Windows environment

Additional Requirements

 Knowledge of claims processing regulatory guidelines/mandates (e.g. HIPAA, Timelines Standards, 

     Medical Terminology, etc.)

 Knowledge of various payment methodologies & government reimbursement guidelines

 Knowledge of claims categorization/codification guidelines (Revenue Codes, Occurrence & Condition 

     Codes, CPT/HCPCS codes, ICD 10 Diagnosis & Procedure Codes)

 Must have basic PC skills

 Related experience field: Medical Claims Experience

 Working knowledge of CPT, ICD-10, Medical Terminology, Coordination of Benefits, and Third Party Liability. 

     Excellent verbal, written and analytical skills

 Demonstrate ability to utilize Medical Terminology and International Classification Diagnosis (ICD-10) coding at a 

     level appropriate to the job

 Must be able to work in fast paced environment

 

Nurse Case Manager

About Us

PremierOne Plus MSO (POPMSO) is a management service organization serving the needs of providers in a managed care setting. PremierOne Plus MSO provides you with the resources and opportunity to build a rewarding career in an environment that support your success.

 

Description

 Responsible for utilization management, utilization review, or concurrent review (telephonic inpatient 

     care management)

 Perform reviews of current inpatient services and determine medical appropriateness of inpatient and 

     outpatient services following evaluation of medical guidelines (MCG) and benefit determination

 Perform medical necessity and level of care reviews for requested medical services and refer to Medical Directors 

    for review as appropriate depending on case development

Responsibilities and Duties

 Performing care management activities to ensure that patients move through the continuum of care efficiently 

     and safely

 Assesses and interprets customer needs and requirements

 Reviewing cases and analyzing clinical information in conjunction with Medical Directors to determine 

     the appropriateness of hospitalization

 Performing Nurse to Physician interaction to acquire additional clinical information or discuss alternatives to 

     current treatment plan

 Escalating cases to the Medical Director for case discussion or peer-to-peer intervention as appropriate

 Performing anticipatory discharge planning in accordance with the patient's benefits and available 

     alternative resources

 Referring patients to disease management or case management programs

 Assisting with the development of treatment plans

 Documenting activities according to established standards

 Identifies solutions to non-standard requests and problems

 Solves moderately complex problems and / or conducts moderately complex analyses

 Works with minimal guidance; seeks guidance on only the most complex tasks

 Provides explanations and information to others on difficult issues

 Acts as a resource for others with less experience

 Works with less structured, more complex issues

 Update and review the case management and utilization management policies and procedures as needed

 Oversee the outpatient UM department

 Work on health plan initiated audits related to case management, utilization management, and related audits

 Submit and implement corrective action plans for issues identified during health plan audits

Qualifications and Skills

Basic Qualifications

 Current and unrestricted RN or LVN License in the State of California

 Clinical experience in an inpatient / acute setting

 Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and 

     devise appropriate courses of action

 Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex 

     or technical information in a manner that others can understand, as well as ability to understand and

     interpret complex information from others

 Intermediate computer skills - Proficiency with Microsoft Word, Outlook and Internet Explorer, with the ability 

     to navigate a Windows environment

Preferred Qualifications

 1 year Utilization Management Inpatient experience

 Utilization Review experience

 Knowledge of or experience with Milliman Care Guidelines

 Experience in discharge planning or chart review

 Experience in acute long term care, acute rehabilitation, or skilled nursing facilities

 A background that involves utilization review for an insurance company or in a managed care environment

 

Internal Medicine Physician

Job description

 Responsible for providing Internal Medicine/Family Practice services to patients. Primary duties may include, but 

     are not limited to:

 Managing a primary care panel of patients daily to improve their health by working with team members 

     and employing population health strategies

 Providing medical patient care by interviewing, examining, and treating clinical patients

 Educating patients and families on wellness, prevention and early detection. Providing referrals based on 

     examination and patient needs.

 Participating in quality improvement, management, continuing education, and patient care programs.

 Assisting in the resolution of complaints, requests, and inquiries from patients.

 Completing medical records (EMR) documentation daily.

 Covering night calls as needed

Qualifications

 Requires an MD or DO degree

 Requires a valid DEA license

 Requires current unrestricted license to practice medicine in California

 MUST speak Spanish or Korean

Salary and Benefits

 From $250,000.00 per year with bonus

 Medical, dental, and vision insurance

 Paid time off/Vacation days

 Paid holidays

 

Job Type: Full-time, Contract

 

Contact: hrdept@popmso.com

 

 

 





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