Prospect Medical Holdings

Case Management Assistant (Inpatient Care Coordinator)

Job Summary:
Receives notification of inpatient admissions, enters in IDX, notifies the appropriate Concurrent Review Nurse, faxes the tracking number to the hospital, requests for and receives Discharge Summaries and distributes them to the Concurrent Review Nurse. Assists the Concurrent Review Nurse on a daily basis. Uploads supporting documentation to Cerecons. Maintains an atmosphere of professionalism and confidentiality.

The following job functions are included, but not limited to:

Checks email for face sheets every hour
Prints face sheets and distributes them to the appropriate Concurrent Review Nurse
Identifies out-of-network facilities and notifies the Concurrent Review Nurse and applicable HP immediately
Calls for initial review and gives the name, telephone number, and fax number to the appropriate Concurrent Review Nurse
Enters new inpatient face sheets into IDX and forwards them to the appropriate Concurrent Review Nurse
Faxes tracking numbers to the hospital admitting office
Requests for and receives Discharge Summaries
Distributes Discharge Summaries to the appropriate Concurrent Review Nurse to coordinate discharge plans
Uploads supporting documentation to Cerecons
Assists the Manager and Vice President of Medical Management with projects as needed

Requirements and/or 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.

Medical Assistant with prior HMO/Medical Group experience
Type 45 wpm (minimum)
Excellent telephone, writing, and spelling skills

Education and/or Experience:

High School Diploma
Certified Medical Assistant and/or Medical Terminology certificate

HCC Risk Adjustment Specialist

Job Summary:
The HCC Risk Adjustment Specialist will perform various audits as assigned by management to ensure physician documentation compliance. The Risk Adjustment Specialist may generate HCFA-1500 claim forms for diagnosis codes found in progress note documentation during an audit. It is the Risk Adjustment Specialists responsibility to forward HCC Claims generated to the HCC Risk Adjustment Analyst on the same day for claim processing. The specialist will forward their audit finding to the HCC Risk Adjustment Manager in a complete and timely manner. The Risk Adjustment Specialist will perform provider training sessions as requested by management. The Risk Adjustment Specialist may make calls to and answer calls from providers and their staff regarding HCC Risk Adjustment Department reports and projects. The HCC Risk Adjustment Specialist is responsible for training new staff members as requested by management, as well as, being a resource for other team members and management.

The following job functions are included, but not limited to:

Perform various audits and special projects as assigned by management
Abstract pertinent information from assigned medical records using ICD-9-CM, CPT and/or HCPCS codes
Provide management with input on provider performance from assigned audits and special projects
Document all chart audit findings in IDX system and applicable audit tools on a daily basis
Ensure audit tools contain adequate evidence to support audit findings and reviews audit tools for accuracy and completeness
Report noncompliance issues detected through auditing
Timely generates and forwards HCC Claims for processing to the HCC Risk Adjustment Analyst
Serve as a resource for internal and external customers to obtain information or clarification on accurate and ethical coding and documentation standards, guidelines and regulatory requirements
Keep abreast of coding guidelines and reimbursement reporting requirements
Adheres to Official Coding Guidelines
Provide one on one provider training and audit sessions as requested by management
Attendance of additional provider training sessions based on departmental needs
Provide support to the HCC Risk Adjustment program with the goal to increase the overall Risk Scores of all IPA's
Research and provide courteous, accurate and timely response to inquires by providers as related to HCC Risk Adjustment projects and reports
Submit bi-weekly and monthly requested workflow reports
Respond to telephone inquires within 24 hours and ensures timely resolution to all issues
Assist other staff members with workflow and resolving issues as requested by management
Assist with new staff training
Assist with reconciliation of Invalid diagnosis list supplied by Claims Department
Assist with chart retrieval from provider office based on departmental needs. This may include some travel with personal vehicle
Other duties as assigned by management based on departmental needs

Ability to effectively utilize audit tools and software
Ability to create and update an Excel spreadsheet for purposes of tracking and reporting
Must be proficient in Microsoft Office with the ability to navigate Word, Excel and PowerPoint
Demonstrate ability to interact effectively with providers and their staff
Outstanding communication skills with the ability to persuasively and effectively communicate with internal and external customers in both written and oral form
Ability to adapt to constantly shifting priorities in managing a wide-range of projects while remaining a team-player
Demonstrate time management, leadership and interpersonal skills
Be able to work both independently and in a team environment with minimal supervision
Ability to make decisions in the absence of detailed instructions
Maintain a positive attitude with changing conditions
Minimum typing speed of forty-five (45) words per minute

Education and/or Experience:

A High School Diploma or Equivalent; BS/BA preferred
Must possess and maintain an AAPC or AHIMA certification— CCS, CCS-P, CPC, CPC-H, CPC-P, RHIT, RHIA
2 - 5 years experience in healthcare setting preferably related to HCC Risk Adjustment and/or chart auditing
Working knowledge of CMS HCC Risk Adjustment methodology
Knowledge of IDX preferred but not required
Statistical application and Mathematical skills, preferred

Manager of Utilization Management

Job Summary:
The Manager of Utilization Management reports to the Executive Director of Utilization Management & Compliance. The Utilization Management Department is a fast pace exciting department which oversees the clinical operations of 10 IPA's in Southern California.

The following job functions are included, but not limited to:

Ensure members receive necessary care in the most cost efficient setting with quality care and quality service
Ensure Healthplan compliance in regards to: reporting, audits, referral determination turn around time and notification to the member and provider
Assist with Healthplan audit preparation to include updating policies and be available to the auditor for assistance/questions the day of the audit
Ensure daily compliance of the referral STAT line, pended referral review process, and maintain internal control for all areas
Ensure Disease Management and Case Management referrals are forwarded to the appropriate staff
Perform Inter Rater Reliability audits of internal clinical staff
Perform daily review as needed of medical necessity cases, retro review, and denial/modification of services
Assign, assist, and manage the pended claim review process
Maintain employee performance reviews

Proficient in Excel and Word
Extremely organized, detail oriented, and the ability to multi task in a fast paced environment
Ability to type 50+ WPM

Education and/or Experience:

RN License
Must have an understanding of Medicare, Medi-Cal, NCQA, and ICE standards/guidelines
Previous HMO experience either in a Medical Group or Healthplan setting, preferably 3 � 5 years
Previous management experience, preferably 3 - 5 years

Nurse Practitioner— RN/LVN

Job Summary:
Temporary Assignment for a licensed and credentialed NP providing diagnosis, treatment, consultation, and follow-up under the supervision of 1 or more physicians from Prospect Medical. The NP provides age and specialty appropriate medical care at the level of training achieved.

The following job functions are included, but not limited to:

Effectively identifies, evaluates and addresses disease prevention and health promotion issues of the population in the practice while administering quality patient care
Works in an independent an interdependent relationship with members of the medical staff, which allows for consultation, collaboration or referral
Responsible for the diagnosis and treatment of acute, chronic, and long-term healthcare issues in skilled nursing facilities
Educates patients and/or families about preventive care, medical issues, and use of prescribed medical treatments and/or medications
Maintains legible, accurate, and confidential medical records. Documents all medical evaluations, diagnoses, procedures, treatment, outcomes, education, referrals, and consultations consistent with NCQA (National Committee for Quality Assurance, JCAHO (Joint Commission on Accreditation of Healthcare Organizations), and state regulatory standards
Facilitates evaluation of records by physician(s), peers, and Quality and Standards according to protocols, and receives and implements constructive directives
Analyzes new knowledge gained from conferences, workshops, professional literature, or "hands-on training" and assimilates this knowledge into clinical practice
This position requires working in Skilled Facilities with members of the facility and doctors

Recommend but not required, knowledge of NCQA, CalOptima, Medicare, Healthplan, DHS and State standards and other regulatory requirements
Recommend but not required knowledge of Microsoft Word and Excel
Make independent decisions
Interact with all employees of the department and providers
Must be able to change thought patterns quickly
Must concentrate for extended periods of time
Have a good driving record and be able to provide a DMV report
Interact with members via phone or face to face

Education and/or Experience:

College graduate with current LVN or RN license
At least 2 year's of concurrent review experience, preferably in a managed care setting

Senior Services Case Manager— RN

Job Summary:
Responsible for obtaining reviews on all senior hospitalized members and concurrent review in hospital or skilled nursing facility. Focus on cost effective, appropriate healthcare.

The following job functions are included, but not limited to:

Check all voice mail at least every 2 hours and respond to messages within 24 hours
Check daily census each morning and update as needed for both acute hospital and skilled facility
Daily update and documentation of admission/concurrent and discharge dates of all inpatient cases
Update specialist information in IDX system as indicated
Inform facility and provider when patient is not eligible or terminated
Assist with referrals for senior case managed members
Special projects assigned by Manager/Director or Medical Director
Coordinates and facilitates all transfers as indicated
Clearly documents all inpatient notes in a timely manner within 48 hours. Discharges to be closed in system within 24 hours.
Review daily with Medical Director and Intensivists
Refer any high acuity, complicated case to appropriate case manager and health plan
Maintain health assessment and disease management as required by health plan

Education and/or Experience:

RN license
Experience in Senior Service department, Medicare and CMS guidelines
Previous experience in HMO medical group/health plan Case Management department

If you are interested in a position above, please send your resume and salary history to: hr@prospectmedical.com. Also please include the job title in the subject line.