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:
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 REQUIREMENTS:
- 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.
- Expertise in ICD, CPT-4, and HCPCS coding structure.
- Knowledge of CMS, DHCS and DMHC regulations required.
- Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and industry standard reimbursement methodologies required.
- Knowledge and familiarity of Health Plan and IPA/Medical Group benefits and contracts and Division of Financial Responsibility (DOFR’s).
- Experience in working CMS Level 1 Appeals and Grievance cases a plus.
- Process all types of claims, such as HCFA 1500, outpatient/inpatient UB04, high dollar claims, COB and DRG claims.
- Responsible for the processing of outpatient/inpatient institutional & professional claims and the comprehensive knowledge of using CMS pricer, 3M Core Grouping Software & Encoder Pro+. Knowledge of DRG, APR-DRG, APC, ASC, & SNF-RUG payment methodologies required.
- Responsible for the processing of claims that are either the financial responsibility of the assigned IPA or capitated Hospital.
- Responsible for validating the diagnosis and procedure codes against the authorized services on Inpatient claims.
- Responsible for the resolution of Provider Disputes (PDR’s) and generate required Acknowledgement and Resolution Letters to send to providers.
- Responsible for requesting additional information required to adjudicate claims by preparing and sending Development Letters and or Notifications to providers.
- Responsible for generating accurate Denial Letters for claims denied as member liability.
- Click here to view the job description
PROVIDER MEMBER OUTREACH - SUPERVISOR
HealthSmart MSO is currently seeking Provider Member Outreach Supervior to assists in the coordination of various projects and activities to include planning, organization, implementation, maintenance, and timely completion of interventions, data manipulation and management, project reporting, and status updates. The Provider Member Outreach Supervisor is responsible for organizing and maintaining multiple projects and programs, reporting requirements, and outreach initiatives. This position requires on-going contact and collaboration with external customers, vendors, and internal staff to provide focused interventions and improvement activities relating to clinical performance measures and functions in an efficient and timely manner.
EDUCATION & EXPERIENCE REQUIREMENTS:
- BA or AA Degree preferred.
- 2+ yrs. HMO/IPA experience preferred, knowledge of Medicare, Medicare Advantage, Medi-Cal and Managed Care experience is preferred.
- Satisfactory completion of a Medical Terminology course required.
- CPT and ICD-10 coding experience preferred.
- Risk adjustment and HEDIS quality experience preferred.
- Experience working in managed health care industry.
- Knowledge of managed care performance measures and quality improvement activities.
- Strong problem solving and organizational/time management skills with the ability to work in a fast paced environment.
- Click here to view the job description
ACCOUNTING COORDINATOR
HealthSmart MSO is currently seeking Accounting Coordinator. Under the supervision of the Controller, the Accounting Coordinator position prepares cash disbursement packages supported by proper purchasing supported by proper purchasing and receiving documentation. Ensures that payments are made in a routine and timely manner.
EDUCATION & EXPERIENCE REQUIREMENTS:
- High school graduate or GED; at least one year of college preferred.
- At least two years experience in accounting or equivalent preferably in a health care environment.
- Good oral and written communication skills and demonstrate and the ability to read, write and communicate fluently in English.
- Must be detail oriented and work well with a team.
- Ability to be crossed-trained in other related areas.
- Responsible for Importing and/or Inputting Capitation and Claims checks into QuickBooks for all IPA’s and Hospital Accounts.
- Responsible for posting daily deposits to the IPA and Hospital cash activity report.
- Prepares and reconciles all bank reconciliation monthly.
- Click here to view the job description
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.
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
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.
- 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.
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.
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.
- 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.
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.
- 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 COORDINATOR
The credentialing coordinator position is responsible for the timely and accurate data entry and processing of provider(s) who are being initially credentialed or recredentialed for a Medical Group/ IPA that adhere to NCQA, CMS/MA, DMHC and DHCS regulations.
EDUCATION/EXPERIENCE REQUIREMENT
- 2 years of previous experience with initial credentialing & re-credentialing experience from a Health Plan, MSO or Hospital setting
- 2 years of previous experience with Word, and Excel
- 2 years of previous experience with handling multiple medical groups/IPA file processing.
- 2 years of previous knowledge working with CAQH Applications or working with California Participating Practitioner Applications
- Working knowledge of ICE Shared auditing for Medical Groups
- Good communication skills