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
HealthSmart MSO, Inc. offers an excellent work environment and is looking for long- term team members to continue with our growth. Come Join Our Team!

We have openings in the following Departments:

SENIOR INSTITUTIONAL CLAIMS EXAMINER
The Senior Institutional Claims Examiner accurately reviews, researches and analyzes professional, ancillary and institutional inpatient and outpatient claims. Essential Functions and Responsibilities of the Job : Knowledge of CPT/HCPC, ICD-10 codes and guidelines. Comprehensive knowledge of DMHC, DHCS and CMS guidelines to accurately adjudicate Medicaid, Commercial and Medicare Advantage claims. Comprehensive knowledge of various fee schedules and CMS pricers for outpatient/inpatient institutional, ancillary and professional claims, including, but not limited to Medicare fee schedules, DRG, APC, ASC, SNF-RUG. EDUCATION/EXPERIENCE:
  • High school graduate, some college preferred.
  • Experience in a managed healthcare environment for a minimum of ten (10) years.
  • Working knowledge of computers and software programs such as Microsoft Word, Excel, Power Point.
  • Excellent verbal and written communication skills, ability to analyze and problem solve.
  • Strong organizational and mathematical skills.
  • Must be detail oriented and work well as a team.
  • Expertise in ICD, CPT-4, and HCPCS coding structure.
  • Ability to generate claims status reports and understanding of EOB.
  • Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and industry standard reimbursement methodologies required.
  • Knowledge of CMS, DHCS and DMHC regulations required.
  • Ability to work independently with limited supervision.
  • Ability to research and resolve claims issuesto appropriately respond to provider, Health Plan, etc.
  • Knowledge and familiarity of Health Plan and IPA/Medical Group benefits and contracts.
  • Experience in working CMS Level 1 Appeals and Grievance cases a plus.
  • Ability to identify and report processing inaccuracies that are related to system configuration.
  • Process all types of claims, such as, HCFA 1500, outpatient/inpatient UB04, high dollar claims, COB and DRG claim
DUTIES/RESPONSIBILITIES:
  • Responsible for the processing of outpatient/inpatient institutional claims and the comprehensive knowledge of using CMS prices, DRG, APC, ASC, SNF-RUG payment methodologies.
  • Responsible for the processing of claims that are either the financial responsibility of the assigned IPA or capitated Hospital.
  • Responsible for the resolution of Provider Disputes and generate required Acknowledgement and Resolution Letters to send to providers.
  • Responsible for requesting additional information required to adjudicate claims by sending Development Letters to providers.
  • Responsible for generating accurate Denial Letters for claims denied as member liability.
  • Run reports and self-audit in order to review payments for inaccuracies prior to check generation.
  • Assist with encounter data processing when needed.
  • Identify system issues and report these to Claims Management so that the system can be enhanced for future auto adjudication.
  • Assist with EDI Provider errors as needed.
  • Mail out Checks and EOBs when needed.
  • Work provider projects for reconciliation when needed.
  • Identify overpayment and submit request to Claims Management for refund.
  • Maintain high level of departmental effectiveness by maintaining good working relationships with all Company personnel.
  • Be a resource for interfacing with other departments for complex issues.
  • Attend internal and external meetings as necessary.
  • Other duties as assigned.
Click here to view the job description
HEALTH PLAN & CLIENT OVERSIGHT MANAGER
HealthSmart MSO is seeking a highly organized individual with managed care Medicare, Commercial and Medi-Cal experience. Must be detail oriented and have working knowledge of health plan auditing, policy writing, and regulatory reporting requirements. Job duties include:
  • Preparation and presentation of reporting to Utilization & Quality Management Committee Meeting(s); including minute taking and follow up. Other meetings, as assigned.
  • Identification, review, analysis and follow-up on utilization trends/risks.
  • Ensuring compliance and timely submission of assigned reporting, including maintenance of logs.
  • Policy and procedure development and updates.
  • Health Plan and regulatory audit preparation, participation and creation of audit activities, corrective action plan writing and implementation.
Candidate’s qualification to have clinical back-ground (LVN) or 5 year(s) experience in managed care healthcare plan or IPA. Working knowledge of Medicare and Medi-Cal policies and procedures. Excellent Excel skills required.
UM STATS SPECIALIST
HealthSmart MSO is seeking a highly organized individual with managed care Medicare, Commercial and Medi-Cal experience. Must be detail oriented and have working knowledge utilization management and data analysis. Job duties include:
  • Preparation of Utilization Management meeting reporting and ensuring accuracy and timely completion.
  • Tracking of monitoring logs.
  • Identification, review, analysis and follow-up on utilization trends/risks.
Candidate’s qualification to have experience in managed care healthcare in an office, plan or at IPA level. Medical Assistant preferred. Excellent organization and advanced Excel skills required.
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.
ACCOUNTABILITY/DUTIES/RESPONSIBILITIES:
  • Accurate processing of referrals for assigned medical group(s), including:
    1. Eligibility verification
    2. Benefit verification
    3. Review of prior activity
    4. Data entry of timely outcome (approval, denial) and follow up
    5. Ensure coordination of services, where necessary
    6. Ensure timeliness of notification to providers (and members, when indicated)
    7. 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
CLAIM SUPPORT
We are currently seeking an individual with excellent customer service skills to provide assistance and support to our Claims Department. This position includes but is not limited to: Clerical functions such as mailing of correspondence, checks, faxing, copying, entry of Charge Tickets into the Claims Processing System and timely and accurate data entry of claims into our eHealth System EDUCATION/EXPERIENCE:
  • High school graduate.
  • Experience working in an office setting.
  • Working knowledge of computers and software programs such as Microsoft Office.
  • Excellent verbal and written communication skills, ability to analyze and problem solve.
  • Strong organizational and mathematical skills.
  • Must be detail oriented and work well with a team.
  • Knowledge in ICD, CPT, and HCPCS coding structure.
  • Must be able to work independently with limited supervision.
DUTIES/RESPONSIBILITIES:
  • Prepare Claims Examiner’s reports in order to run checks.
  • Accurately count the number of checks needed by IPA/Hospital.
  • Log the number of checks requested by IPA/Hospital.
  • Run checks and EOBs
  • Reconcile checks and EOBs in order to scan for Finance and Claims.
  • Staple and prepare for either meetings or mailing to the appropriate Board Member for signature.
  • Log checks in order to follow up with IPAs that exceed more than 7 days of not returned from signature.
  • Prepare checks for mailing once completed with signatures.
  • Mailing of checks and EOBs within 48 hours of receipt.
  • Charge the correct client account for postage of mail outs from the Claims Dept.
  • Correct EDI errors from Office Ally and UBs from Calibrated.
  • Identify and notify Management of ongoing issues with the error reports in order to minimize the number of errors on future inloads.
  • Fix provider errors identified in eHealthcare based on the EDI errors.
  • Pull claims for audits when needed.
  • Regenerate EOBs for Claims staff when needed.
  • Enter and process capitated claims, create invoice for Finance on a monthly basis.
  • Organize and file claims checks and backup in the assigned File Cabinets based in IPA.
  • Attend internal meetings as necessary.
  • Other duties as assigned.
Click here to view the job description
SENIOR INSTITUTIONAL (HOSPITAL) CLAIMS EXAMINER
The Senior Institutional Claims Examiner accurately reviews, researches and analyzes professional, ancillary and institutional inpatient and outpatient claims. Essential Functions and Responsibilities of the Job : Knowledge of CPT/HCPC, ICD-10 codes and guidelines. Comprehensive knowledge of DMHC, DHCS and CMS guidelines to accurately adjudicate Medicaid, Commercial and Medicare Advantage claims. Comprehensive knowledge of various fee schedules and CMS pricer for outpatient/inpatient institutional, ancillary and professional claims, including, but not limited to Medicare fee schedules, DRG, APC, ASC, SNF-RUG. EDUCATION/EXPERIENCE:
  • High school graduate, some college preferred.
  • Experience in a managed healthcare environment for a minimum of ten (10) years.
  • Working knowledge of computers and software programs such as Microsoft Word, Excel, Power Point.
  • Excellent verbal and written communication skills, ability to analyze and problem solve.
  • Strong organizational and mathematical skills.
  • Must be detail oriented and work well as a team.
  • Expertise in ICD, CPT-4, and HCPCS coding structure.
  • Ability to generate claims status reports and understanding of EOB.
  • Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and industry standard reimbursement methodologies required.
  • Knowledge of CMS, DHCS and DMHC regulations required.
  • Ability to work independently with limited supervision.
  • Ability to research and resolve claims issues to appropriately respond to provider, Health Plan, etc.
  • Knowledge and familiarity of Health Plan and IPA/Medical Group benefits and contracts.
  • Experience in working CMS Level 1 Appeals and Grievance cases a plus
  • Ability to identify and report processing inaccuracies that are related to system configuration.
  • Process all types of claims, such as, HCFA 1500, outpatient/inpatient UB04, high dollar claims, COB and DRG claim
DUTIES/RESPONSIBILITIES:
  • Responsible for the processing of outpatient/inpatient institutional claims and the comprehensive knowledge of using CMS prices, DRG, APC, ASC, SNF-RUG payment methodologies.
  • Responsible for the processing of claims that are either the financial responsibility of the assigned IPA or capitated Hospital.
  • Responsible for the resolution of Provider Disputes and generate required Acknowledgement and Resolution Letters to send to providers.
  • Responsible for requesting additional information required to adjudicate claims by sending Development Letters to providers.
  • Responsible for generating accurate Denial Letters for claims denied as member liability.
  • Run reports and self-audit in order to review payments for inaccuracies prior to check generation.
  • Assist with encounter data processing when needed.
  • Identify system issues and report these to Claims Management so that the system can be enhanced for future auto adjudication.
  • Assist with EDI Provider errors as needed.
  • Mail out Checks and EOBs when needed.
  • Work provider projects for reconciliation when needed.
  • Identify overpayment and submit request to Claims Management for refund.
  • Maintain high level of departmental effectiveness by maintaining good working relationships with all Company personnel. Be a resource for interfacing with other departments for complex issues.
  • Attend internal and external meetings as necessary.
  • Other duties as assigned.
SENIOR CLAIMS EXAMINER
We are currently seeking a highly experienced Senior Claims Examiner who is responsible for the timely adjudication of claims and resolution of provider disputes that have been determined to be the financial responsibility of the assigned IPA. Responsible for answering calls coming through the ACD line. EDUCATION/EXPERIENCE:
  • High school graduate, some college preferred.
  • Experience in a managed healthcare environment for a minimum of ten (10) years./li>
  • Working knowledge of computers and software programs such as Microsoft Word, Excel, Power Point.
  • Excellent verbal and written communication skills, ability to analyze and problem solve.
  • Strong organizational and mathematical skills.
  • Must be detail oriented and work well as a team.
  • Expertise in ICD, CPT-4, and HCPCS coding structure.
  • Ability to generate claims status reports and understanding of EOB.
  • Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and industry standard reimbursement methodologies required.
  • Knowledge of CMS, DHCS and DMHC regulations required.
  • Ability to work independently with limited supervision.
  • Ability to research and resolve claims issues to appropriately respond to provider, Health Plan, etc.
  • Knowledge and familiarity of Health Plan and IPA/Medical Group benefits and contracts.
  • Experience in working CMS Level 1 Appeals and Grievance cases a plus.
DUTIES/RESPONSIBILITIES: Support Claims Management with the following:
  • Responsible for the process of claims that are either the financial responsibility of the assigned IPA or capitated Hospital.
  • Responsible for the resolution of Provider Disputes and generate required Acknowledgement and Resolution Letters to send to providers.
  • Maintain a minimum average of 85 claims processed per day and 40 PDRs processed per day.
  • Responsible for requesting additional information required to adjudicate claims by sending Development Letters to providers.
  • Responsible for generating accurate Denial Letters for claims denied as member liability.
  • Run reports and self-audit in order to review payments for inaccuracies prior to check generation.
  • Assist with encounter data processing when needed.
  • Identify system issues and report these to Claims Management so that the system can be enhanced for future auto adjudication.
  • Assist with EDI Provider errors as needed.
  • Mail out Checks and EOBs when needed.
  • Work provider projects for reconciliation when needed.
  • Identify overpayment and submit request to Claims Management for refund.
  • Maintain high level of departmental effectiveness by maintaining good working relationships with all Company personnel. Be a resource for interfacing with other departments for complex issues.
  • Provide excellent customer service to the physicians and clients calling in via the ACD Line in regard to claims.
  • Attend internal and external meetings as necessary.
  • Other duties as 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 highly desirable.
  • HMO, Medi-Cal/Medicaid and health services experience preferred.
Click here to view the job description
RISK -ADJUSTMENT MANAGER
The Risk-Adjustment Manager will act as liaison between IPA/MSO, contracted physicians and other providers (ancillary) and Health Plans. This position maintains the credibility of the Quality Management department by performing medical/clinical chart review and data collection, analysis and coding to capture and obtain data and information related to risk adjustment, STAR/HEDIS and other quality and performance improvement measures and metrics. Maximize clinical diagnosis codes captured from retrospective and prospective chart review processes, as well as improve coding and data capture of quality/performance measures and initiatives. Performs medical record reviews at contracted provider practices for completeness, accuracy, compliance with Federal and State laws, regulations and coding guidelines. Serves as a liaison between organization, medical group and physicians. Must be able to communicate/interact effectively and work collaboratively with physicians, other clinical/office staff and other members of the team regarding various projects and initiatives. This position will require physician/provider/staff education on proper documentation and coding of diagnoses codes (ie, HCC, CDPS, Risk-Adjustment) to follow coding guidelines, monitor completion of required member preventive services (ie. STAR, HEDIS, Quality measures), as well as determine physician compliance and improvement. Must be able to generate required reports and protect the confidentiality of all quality management information in accordance with department policies. The Risk-Adjustment Manager oversees all HCC/CDPS/Risk-Adjustment projects, activities and compliance for all lines of business; participates in reviewing current data collection and reporting processes, identifying and recommending process improvement practices, and making recommendations to the health care team members for implementing timely interventions and provider in-services, with the main objective of increasing the MSO and Client’s Risk Adjustment scores (ie. HCC, CDPS, etc.) and their STAR, HEDIS and other Quality/Performance Improvement rates. EDUCATION & EXPERIENCE REQUIREMENTS:
  • Current and valid AHIMA and/or AAPC Certified Coding Specialist (CCS), Registered Health Information Technology (RHIT) or Certified Professional Coder (CPC) required. AA and/or BA Degree in related field preferred. Credentials must be maintained during employment.
  • Strong knowledge of medical records, medical anatomy and terminology, ICD-10-CM and CPT codes, CMS-HCC model and documentation guidelines, NCQA HEDIS/P4V clinical measures, and State CDPS risk adjustment programs. Experience with Orange County CalOptima Risk-Adjustment Programs (ie. Medi-Cal CDPS) a plus.
  • Minimum three (3) years of risk-adjustment/HCC methodology experience and coding, with emphasis in managed care environment within Health Plans or Medical Groups; strong chart audit, review experience and data abstraction skills with focus on provider education and outreach.
  • Experience in the Managed Care setting with Medicare Advantage, Cal Medi-Connect, Medi-Cal and Covered CA, Commercial Insurance Programs. Familiarity with state and federal laws and professional standards necessary.
  • Experience working as liaison with physicians, clinical/medical staff, other providers, members, and Health Plans.
  • Bachelor's degree or higher, preferred.
RISK-ADJUSTMENT ANALYST
The risk adjustment analyst will work directly with the risk adjustment manager to support the organization’s revenue and the group’s overall performance. The position will assist to maximize clinical diagnosis codes captured from a retrospective and prospective chart review processes, as well as improve coding and data capture of quality/performance measures. She/he performs medical record reviews at contracted provider practices for completeness, accuracy, compliance with Federal and State laws, regulations and coding guidelines; serves as a liaison between organization, medical group and physicians. Additional duties and responsibilities will be assigned. EDUCATION REQUIREMENT
  • AHIMA and/or AAPC Certified Coding Specialist (CCS), Registered Health Information Technology (RHIT) or Certified Professional Coder (CPC) required.
  • AA and/or BA Degree in related field preferred.
EXPERIENCE/KNOWLEDGE and SKILL REQUIREMENTS
  • Current Coding Certification (CPC, CCS, RHIT) through AAPC and AHIMA is mandatory. Valid credentials must be maintained during employment.
  • 2+ years risk adjustment/HCCs experiences methodology required with an emphasis in a managed care environment within the health plan or medical groups, strong chart review auditing and data abstraction skills.
  • Knowledge of CMS-HCC model, Medi-Cal and commercial coding and documentation guidelines.
  • Ability to interpret, analyze and abstract data based on the provider documentation.
  • Ability to identify HCC coding improvement opportunities and provide feedback to physicians on proper clinical documentation, compliance and coding guidelines.
  • Knowledge of medical anatomy and terminology, ICD-10- CM and CPT codes, CMS-HCC model and documentation guidelines, NCQA HEDIS/P4V clinical measures, and State CDPS risk adjustment programs.
  • Computer proficiency in MS Office (Excel with Pivot tables, functions, Word and Power Point).
  • Excellent organizational, time management and problem-solving skills; detail-oriented; must possess a high degree of accuracy, efficiency and dependability.
  • Must be available and willing to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet projects, deadlines and its business needs.
QM OUTREACH SUPPORT
This position is responsible for project organization and maintenance, monthly/quarterly/annual reporting, member/provider outreach and any additional support as needed. This position assists in the coordination of various projects and activities to include planning, organization, implementation, maintenance, and timely completion of interventions, data manipulation and data management, project reporting, and status updates. QUALIFICATIONS
  • High School Diploma; Concurrent college enrollment required.
  • Experience working in managed health care industry.
  • Knowledge of managed care quality/performance programs, HEDIS/STAR, HCC/CDPS risk-adjustment and related timelines and activities.
  • Data collection and project coordination/organization experience required.
  • Advanced knowledge software programs such as Microsoft Word, Excel, and Access, including analytical functions, pivot tables, etc.
  • Excellent oral and written communication skills.
  • Strong research, methodology, and analytical skills; advanced organizational skills and attention to details; excellent time management skills with the ability to prioritize and work under pressure in a fast paced environment; manage several tasks and projects simultaneously.
  • Ability to work with multiple cross-functional project teams in order to meet project schedules, costs, and performance objectives.
Click here to view the job description
RISK-ADJUSTMENT CODER and QUALITY LIAISON
The risk adjustment coder and quality liaison will work directly with the risk adjustment manager to support the organization’s revenue and the group’s overall performance. The position will assist to maximize clinical diagnosis codes captured from a retrospective and prospective chart review processes, as well as improve coding and data capture of quality/performance measures. She/he performs medical record reviews at contracted provider practices for completeness, accuracy, compliance with Federal and State laws, regulations and coding guidelines; serves as a liaison between organization, medical group and physicians. Additional duties and responsibilities will be assigned. EDUCATION REQUIREMENT
  • AHIMA and/or AAPC Certified Coding Specialist (CCS), Registered Health Information Technology (RHIT) or Certified Professional Coder (CPC) required.
  • AA and/or BA Degree in related field preferred.
EXPERIENCE/KNOWLEDGE and SKILL REQUIREMENTS
  • Current Coding Certification (CPC, CCS, RHIT) through AAPC and AHIMA is mandatory. Valid credentials must be maintained during employment.
  • 2+ years risk adjustment/HCCs experiences methodology required with an emphasis in a managed care environment within the health plan or medical groups, strong chart review auditing and data abstraction skills.
  • Knowledge of CMS-HCC model, Medi-Cal and commercial coding and documentation guidelines.
  • Ability to interpret, analyze and abstract data based on the provider documentation.
  • Ability to identify HCC coding improvement opportunities and provide feedback to physicians on proper clinical documentation, compliance and coding guidelines.
  • Knowledge of medical anatomy and terminology, ICD-10- CM and CPT codes, CMS-HCC model and documentation guidelines, NCQA HEDIS/P4V clinical measures, and State CDPS risk adjustment programs.
  • Computer proficiency in MS Office (Excel with Pivot tables, functions, Word and Power Point).
  • Excellent organizational, time management and problem-solving skills; detail-oriented; must possess a high degree of accuracy, efficiency and dependability.
  • Must be available and willing to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet projects, deadlines and its business needs.
CREDENTIALING ASSISTANT
As a credentialing assistant this position is responsible for timely and accurate data entry into our eHealth System, mailing out re-credentialing applications with tracking until the application is received for all our contracted IPA’s and filing of expirable documents while learning principles of adherence to NCQA, CMS, DMHC and DHCS regulations. EDUCATION/EXPERIENCE REQUIREMENTS:
  • High school graduate
  • At least two years credentialing experience
  • Good communication skills
  • Working knowledge of Windows Word, and Excel
  • Detail oriented
  • Ability to use Outlook 2016
DUTIES/RESPONSIBILITIES:
  • Responsible for the credentialing and recredentialing of IPA providers pursuant to NCQA, DHS, DMHC and CMS guidelines.
  • Responsible for accurately data entering initial credentialing and recredentialing applications in the Credentialing Data Management system in a timely manner.
  • Maintain practitioner files ensuring that current information is placed in provider's credentialing files (i.e. license, DEA, malpractice insurance certificates) in a timely manner.
  • Prepares credentialing/recredentialing files including primary source verifications and assures that credentialing information is consistently placed in file in orderly manner and on a daily basis.
  • Responsible for computer generating all verification request letters and sending to appropriate agencies on a daily basis for credentialing/recredentialing files.
  • Responsible for performing online verifications, if available, for primary source verification for credentialing/recredentialing files.
  • Responsible for opening the mail, date stamping and entering into Data Management system in a timely manner.
  • Responsible for identifying and generating forms for providers whose documents are due to expire, ensuring that current documents are received, data entered and placed in provider's files in a timely manner.
  • Communicates with practitioners to resolve any issues in a timely and professional manner.
  • Assists in the updating and distribution of IPA provider rosters.
  • Responsible for photocopying any documents required and faxing if necessary.
  • Assists the Department with any special projects.
  • Answers telephone promptly and professionally.
  • Assures confidentiality of Credentialing/Peer Review/QM activities.
  • Other duties as assigned.