Represents Partnership in the Grievance & Appeals Resolution process. Responsible for reviewing, investigating, and resolving assigned member grievance and appeal cases ranging from low to high complexity. Works to transform member dissatisfaction into member satisfaction. Oversees the investigative process ensuring casework complies with DHCS guidelines, NCQA standards,

The Policy Analyst will be responsible for drafting, editing, reviewing, auditing, tracking, monitoring and maintaining policies and procedures for Partnership HealthPlan of California. Alongside designated organizational leadership, ensures compliance with governing rules, regulations, and/or accreditation standards. Reviews both draft and final All Plan Letters (APLs)

To research and resolve provider telephone and written inquiries within established timeframes, accurately screen claims, and participate in provider meetings and projects. Support for either escalated calls or to accept calls of a more complex nature requiring additional skills. To provide support to CSR staff when call volume requires additional personnel. Routinely process CIFs as part of their daily workload.

To provide coordination and implementation support of defined tasks for the assigned program(s).

To provide coordination and implementation support of defined tasks for the assigned program(s).

To respond to member and provider issues and inquiries. Ensures that callers’ questions and/or problems are resolved or are directed to the appropriate person for resolution and provides the highest level of customer service.

To review, research, and resolve claims for all Medi-Cal claim types within established production and quality standards, including manual processing. Completes and processes claims and claims worksheets. Creates appropriate documentation that reflects the actions taken and status of the claim. Generates provider communication, such as letters, as necessary. Routes and tracks claims requiring review by other staff and departments, and processes when possible. Claims Examiner II is distinguished from Claims Examiner I by a higher level of autonomy and experience, as well as an ability to process a wider range of claim types.

To design, develop, and test client server and web applications at PHC. To work with the Director, Web Applications Development in the design, development, testing, and deployment of web and desktop applications. Works closely with IT staff in developing applications in business needs supporting AMISYS Advance and networked systems. Assumes senior role in developing applications and supporting existing applications and other applications, as appropriate.

Responsible for the development of all processes necessary to complete SDLC phases of the Web Applications and Automation projects. This includes understanding of business processes, source identification, process design, data collection, data transformation, normalization, error detection and correction, data storage, data linage management, data achieving, and ETL Process oversight for web applications.

The Data Integration Developer is responsible for designing, developing, and maintaining data integration solutions with a focus on EDI (Electronic Data Interchange) for healthcare applications. This role involves implementing ETL processes, managing data pipelines, ensuring data quality, and generating reports to support business intelligence and compliance with

The Regulatory Affairs Specialist II has demonstrated competencies in supporting the plan-wide regulatory affairs and compliance program, including activities related to HIPAA, Fraud, Waste, and Abuse (FWA), and compliance issues. As such, conducts investigations to effectively prevent, detect, and mitigate healthcare FWA, privacy and compliance issues. Supports daily operations of the Regulatory Affairs unit by ensuring deliverables and all case management performance metrics are met for assigned cases. This position serves as an investigative liaison between the plan and our regulatory agencies and internal departments.

To respond to member and provider issues and inquiries. Ensures that callers’ questions and/or problems are resolved or are directed to the appropriate person for resolution and provides the highest level of customer service.

To begin Treatment Authorization Requests (TAR) reviews and perform data entry upon TAR determination by pharmacy staff. Performs eligibility and benefit investigations. Supports pharmacy department with extracting and collecting data for reporting needs. Supports department's administrative needs, and participates in special projects as assigned by pharmacy technician lead, supervisor, and departmental staff.

To facilitate access to medical care by coordinating Non-Emergency Medical (NEMT) Transportation, Non-Medical Transportation (NMT) transportation and travel-related benefits for members. Coordinates care in collaboration with internal and external partners to help members overcome barriers to care created by lack of transportation.

To develop, implement, improve, and manage assigned programs. The Program Manager I is responsible for the overall success for the assigned program(s) and their role extends beyond completion of individual tasks. Programs are ongoing, which may include aligned projects and requires strategic planning and continuous improvement efforts after program startup.

The Senior Healthcare Data Analyst I contributes to the overall success of the organization by developing analytic solutions that support activities related to health services utilization management, care coordination, quality improvement and population health. Through analyzing patient claims, member enrollment, and other data, the Senior Healthcare Data Analyst

The Senior Healthcare Data Analyst I contributes to the overall success of the organization by developing analytic solutions that support activities related to health services utilization management, care coordination, quality improvement and population health. Through analyzing patient claims, member enrollment, and other data, the Senior Healthcare Data Analyst

To respond to member and provider issues and inquiries. Ensures that callers’ questions and/or problems are resolved or are directed to the appropriate person for resolution and provides the highest level of customer service.

To gather and validate healthcare practitioner credentialing information in accordance with regulatory and accreditation standards. Interacts with practitioners by phone to ensure timely receipt of information. Responds to inquiries via telephone and email.

Under the direction of the Director of Quality and Performance Improvement (QI/PI), the Manager of Performance Improvement is responsible for key initiatives within the QI/PI Department: - The Partnership Improvement Academy and its associated programs; - Strategic, organization-wide improvement initiatives; - Focused...