Career Opportunities
How to Apply
- Online – by Email
Email your cover letter and resume. Please included your salary requirements to: HealthSmartHR@healthsmartmso.com - Letter – by mail
Mail your resume with work history. Please included your salary requirements to address:
HealthSmart MSO, Inc.
Attn: Human Resources P.O. Box 6300 Cypress, CA 90630-6300
UTILIZATION MANAGEMENT NURSE REVIEWER
HealthSmart Management Services Organization, Inc. is looking for a full-time qualified UM Nurse Reviewer who will be responsible for reviewing and processing Authorization requests of medical services from health professions, clinical facilities and ancillary providers. Qualified candidate will coordinate with Providers and their office designees as a resource for their various inquiries and needs.
EXPERIENCE & EDUCATION:
- High School Graduate or equivalent required.
- Current unrestricted RN or LVN License to practice in the State of California.
- Minimum of three (3) years current clinical experience preferred.
- IPA and Managed care experience preferred.
- Knowledge of medical criteria for Apollo, MCG and Medicare/Medi-Cal guidelines.
- Excellent telephone skills required.
- Computer experience desirable.
- Excellent interpersonal skills.
- ICD 10- CM and CPT/ HCPCS Medical Coding
- Strong problem solving, organizational skills and time management skills with the ability to work in a fast-paced environment. ACCOUNTABILITY & DUTIES & RESPONSIBILITIES
- Accurate processing of referrals for assigned medical group(s), which includes:
- Eligibility verification
- Receives reviews, verifies and processes requests for referrals, diagnostic testing, inpatient admissions, outpatient procedures/testing, emergency room notification, home health care services, and durable medical equipment and supplies via telephone, fax or on-line portal.
- Reviewing all adverse decisions for accuracy of member-specific information and appropriateness of lay language regarding the Physician Reviewer’s decision. Works closely with Denial Coordinator, Physician Reviewer, and Director of Utilization Management for use of criteria/guidelines
- Utilization of mandatory UM Nurse documentation to include Hierarchy of criteria used to either make decision (based on IPA Matrix) or to assist Physician Reviewers in criteria review.
- Reviews for potential CCS eligible conditions and notify appropriate CCS designated staff for processing.
- Review of prior activity.
- Ensure coordination of services, where necessary.
- Ensure timeliness of notification to providers (and members, when indicated.
- Timely processing of referrals for assigned medical group(s) according to timeliness chart.
- Maintain coordination of services between health plans, CCS, Case Management, Linked services, etc.
- Maintain professional interaction with Medical Directors, Physician Reviewers, IPA Physicians and staff, Nurse/Case Managers for Outpatient coordination of Case Management cases, Fellow coworkers, etc.
- Maintain compliance with UM Plan and Policy and Procedures as related to your role as a Nurse Reviewer.
- Maintain compliance with HIPAA rules and regulations.
CUSTOMER SERVICE REPRESENTATIVE
We are currently seeking a service-oriented individual with excellent customer service skills to provide assistance to our members and providers via telephone. Must be able, to work in a fast paced call center environment answering member questions, processing and documenting information, and providing follow-up assistance as needed.
Experience & Education:
- High school diploma or equivalent required.
- Minimum 2 years' experience in a customer/member service or call center capacity.
- Bilingual skills in English-Spanish and/or English-Korean highly desirable.
- HMO, Medi-Cal/Medicaid and health services experience preferred.