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
We have openings in the following Departments:
PERSONAL CARE COORDINATOR
This position will serve as a liaison between OneCare members, the IPA, CalOptima, medical providers, behavioral health providers and Long Term Support and Service (LTSS) providers. The Personal Care Coordinator (PCC) will identify and reduce barriers to members’ care, assist the member in locating and accessing resources and educate the member on the importance of accessing care promptly. The PCC will serve as the primary point of contact for the member and will be an integral part of the member’s interdisciplinary care team. The PCC provides support to the member as they self-navigate the health care system. The PCC works closely with member’s case management team to resolve access, medical and psychosocial related issues. The PCC must be able to efficiently manage and prioritize a caseload of 400 members. The PCC will work under the direct supervision of a licensed clinical professional to ensure optimal coordination of care for the OneCare members.
EDUCATION-SKILLS-EXPERIENCE REQUIREMENT:
Medicare and Medi-Cal eligibility and benefits preferred.
Long term services and supports.
Issues that face members with special needs, such as seniors and persons with disabilities.
Principles and practices of health care service delivery and managed care, Medi-Cal/Medicare CalOptima eligibility and benefits.
Principles and techniques to serve the SPD population in diverse social and ethnic groups.
Effective charting practices and guidelines.
Personal computers, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.
- 2+ years’ experience working with the needs of seniors or persons with disabilities (SPD) in a customer/member service capacity or similar experience.
- HMO, Medi-Cal/Medicare and health services experience preferred.
- Bilingual in English/Spanish or English/Vietnamese is preferred.
- Collaborates with CalOptima PCC to ensure timely communication of member’s clinical information
- Guide members in understanding and accessing the benefits they are entitled to under Medicare and Medi-Cal, through the OneCare program.
- Assist with coordination of member’s health care and social service needs both within and outside the IPA and CalOptima.
- Facilitate communication of HRA and initial care plan to the primary care physician (PCP), IPA, CalOptima and member, as indicated.
- Assist member in meeting their preventive care goals.
- Facilitate referrals to LTSS, behavioral health and community resources.
- Initiate referrals to both internal and external care management departments and other department/government or community agencies as directed by the case manager.
- Facilitate transfers directly to member’s assigned case manager in accordance with member needs, when appropriate.
- Prompt communication of member’s case notes, HRA, care plan and interdisciplinary care team (ICT) proceedings to CalOptima’s PCC for integration in CalOptima’s medical management system.
- Notify member’s care team of key event triggers.
- Participate in ICT meetings, as appropriate.
- Other projects and duties as assigned.
- Maintain accurate records and documentation.
- Develop rapport, establish and maintain effective interpersonal relationships with internal and external contacts at all levels.
- Work with Case Management staff to expedite the resolution of member concerns.
- Remain knowledgeable of OneCare’s benefit structure.
- Communicate effectively, both verbally and in writing with individuals from varying cultural and ethnic backgrounds.
NURSE, CONCURRENT REVIEW CASE MANAGER
To ensure coordination of timely and appropriate care for all hospitalized members; To ensure the delivery of cost-efficient, appropriate health care services for all members; To ensure members with complex and chronic care needs are addressed; To ensure plan for coordination among all disciplines; To ensure that medically necessary care is delivered for members that require extensive on-going service; Identification of any potential quality issues.
EDUCATION-SKILLS-EXPERIENCE REQUIREMENT:
- Licensed Vocational or Registered Nurse with valid California Nursing License.
- Experience in telephonic concurrent review process.
- Experience in Case Management in hospital, IPA or managed care environment.
- Knowledge of medical criteria for length of stay and/or experience with Milliman and/or Interqual Healthcare Guidelines
- Basic computer data entry experience.
- Knowledge of CPT/ ICD-10 coding.
- Maintain compliance with UM Plan and Policies and Procedures as related to your role of Nurse, Case Manager
- Coordinate daily Concurrent Review activity for assigned IPAs/Medical Groups, by coordinating with Hospital Case Managers, Health Plans, Primary Care Physicians, Medical Director, Hospitalists, etc.
- Identify Estimated Length of Stay and necessity using Apollo, Interqual and/or Milliman Healthcare Guidelines.
- Ensure review appropriateness (IP criteria met) of admission within 24-hours of notification.
- Coordinate and ensure timely discharge planning with appropriate contracted ancillary providers.
- Identify Potential CCS Eligible conditions and coordinate with CCS Coordinator. Assist with obtaining CCS authorization and logging in system.
- Identify and refer cases for outpatient Case Management using criteria and support activities.
- Ensure documentation of denial of service. Ensure denial letter is sent within 24 hours of the denial decision.
INTAKE COORDINATOR
Assist in all case management and concurrent review activities for assigned IPA(s), ensuring timeliness and accuracy. Responsible for opening and maintaining case management files for assigned IPA(s).
EDUCATION & EXPERIENCE REQUIREMENTS
- High School Graduate.
- Medical Assistant, experience in Managed Care and/or referral processing, preferred.
- Experience in managed care environment.
- ICD-9, and ICD-10 coding experience.
- Organization, Data Entry and Filing Skills.
- Accurate and timely processing of concurrent review referrals for assigned medical group(s), including:
- Eligibility verification
- Benefit verification against established criteria for inpatient hospitalizations
- Review of prior activity
- Timely data entry
- Ensure coordination of services, where necessary
- Ensure timeliness of notification to providers
- Maintain accurate detailed notes of activity related to inpatient hospitalizations
- Responsible for monitoring and delivering of all information received via the Fax, including:
- Accurate date stamping
- Timely & accurate delivery
- Maintenance of Fax machine
- Responsible for opening and maintaining case management files, including:
- Creating new cases in Concurrent Review Module
- Checking eligibility and attaching records to the electronic file
- Completing Medical Record Request form and faxing to facilities
- Maintaining E-Health system indicating open and closed cases
- Maintain professional interaction with Medical Directors, Physician Reviewers, IPA Physicians and staff/coworkers, etc.
- Report any delays in obtaining the required records and data entry of authorization to Supervisor.
- Obtain assistance and direction with difficult authorizations from UM Supervisor or UM Lead.
- Maintain compliance with HIPAA rules and regulation.
- Mailing, as required.
- Other duties, as identified/assigned.
- Click here to view the job description
UM COORDINATOR
Assist in all UM referral activity for assigned Medical Group(s), ensuring timeliness and accuracy.
EDUCATION & EXPERIENCE REQUIREMENTS
- High School Graduate.
- Certified Professional in Utilization Management (CPUM) or Certified Professional in Utilization Review (CPUR) or Medical Assistant with 2 years experience in UM.
- Experience in managed care environment.
- ICD-10, CPT and referral processing experience.
- Data Entry Skills.
- Accurate processing of referrals for assigned medical group(s), including:
- Eligibility verification
- Benefit verification
- Review of prior activity
- Data entry of timely outcome (approval, denial) and follow up
- Ensure coordination of services, where necessary
- Ensure timeliness of notification to providers (and members, when indicated)
- Maintain accurate detailed notes of activity related to referrals.
- 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.
- Report any delays in authorization to UM Supervisor or Lead
- Obtain assistance and direction with difficult authorizations from UM Supervisor or UM Lead.
- Maintain and update Matrix logs.
- Maintain Inter-rater reliability score of 95%. Implement any requests for corrective action immediately.
- Maintain compliance with HIPAA rules and regulation.
- Other duties, as identified/assigned.
- Click here to view the job description
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.