Provides advisory and technical services to all of the HealthPlan’s contact center organizations (Member Services, Health Services, Claims, Provider Relations, and Administration) in the areas of operations, system enhancement and configuration, report generation, knowledge management, and training. Conducts business and technical requirements analysis, testing, and execution in support of the development of PHC’s contact center systems enhancements and reports. Develops and maintains an understanding of PHC’s contact center systems and reporting tools as an administrator and a user. Develops and delivers custom daily, weekly, monthly, quarterly, and yearly reporting with...

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.  Participates in the design, implementation, and/or expansion of strategic programs and departmental initiatives. Supports the development and execution of program goals, outcome measures, and program reporting.

To coordinate medically necessary behavioral health treatment services for adults and children with behavioral health needs. Screens, collaborates and coordinates care as part of the multidisciplinary team to evaluate and advocate for the medical, behavioral and psychosocial needs of the member while promoting quality outcomes.

Under the direction of Grievance Supervisor, the Grievance and Appeals Associate is responsible for monitoring all incoming cases, recording them in Everest, and assigning new cases to the appropriate Grievance Staff.   Provides clerical support to Grievance Staff by ensuring all correspondence is printed and mailed timely, according to DHCS timeframes and HIPAA confidentially laws.  Responsibilities also include accepting incoming calls on the ACD phone system, assisting customers.  Performs other administrative and/or clerical support to the department and/or management as needed.

The Enrollment Specialist I will assist in maintaining Medi-Cal membership and process basic functions of the Enrollment Unit. This position will review, research, and resolve Medi-Cal eligibility issues and systems related errors as well as primary care physician (PCP) assignment failures within established production and quality standards. Completes and processes reports and appropriately documents member records of actions taken to correct or update member records, PCP assignments etc. Processes reports to ensure primary care assignment is appropriate, processes certain authorized representative forms and document members records appropriately. Reports eligibility discrepancies and deceased members to appropriate counties and adds newborn records upon request...

In collaboration with Care Coordination team members, this position provides support and guidance to HealthPlan members referred to the Care Coordination Department for Case Management services and programs. The Health Care Guide I works closely with members, families, providers, community agencies, and the interdisciplinary care team to assist in coordination of benefits in a timely and cost-effective manner, while connecting members to available internal and external resources.

Provide a range of social work services in collaboration with PHC staff to meet the psycho-social and care coordination needs of members. Responsible for the assessment and care coordination of the psycho-social needs of members, families and/or caregivers to help promote positive coping skills, reduce the risk of premature institutionalization, assist individuals in maintaining independence in the community and increase stabilization of social determinants.

The Coordinator I will provide coordination and administrative support to department teams and management. Performs a variety of general clerical duties, including data entry, report generation, manage and respond to call inquiries, manage internal Helpdesk inquiries, manage and assign follow up inquiries from other departments, creates and revises desktop protocols, and develops forms and presentations.

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.  Participates in the design, implementation, and/or expansion of strategic programs and departmental initiatives. Supports the development and execution of program goals, outcome measures, and program reporting.

Under the direction of the Manager of Performance Improvement, the Improvement Advisor is uniquely positioned to drive improvement across PHC, our provider network, and the communities we serve. The Improvement Advisor will work internally and externally with provider practices and community partners to identify, plan, and facilitate quality improvement projects. Via individualized facilitation, this position will coach and train improvement teams to build team members’ quality improvement (QI) skills, develop their organizational capacity for QI work, and help them meet their specific QI goals. In addition to working directly with improvement teams, the Improvement Advisor will join PHC’s Performance...

The Quality Data Validation Analyst is responsible for improving the quality and completeness of data used for Partnership’s Healthcare Effectiveness Data Information Set (HEDIS) reporting initiative. This position will focus on sets of measures required by federal and state regulatory bodies and collaborates with internal and external stakeholders to improve the exchange of clinical data that meets the requirements for use in the reporting and ensures that services completed within Partnership’s provider network are accurately leveraged in the HEDIS Project. This position is a key stakeholder on Partnership’s implementation of a Data Aggregator vendor solution and will partner with the vendor and internal...

 Responsible for developing, contracting, implementing, and maintaining new and existing provider networks. Manage and monitor contractual relationships with existing PHC contracted providers. Assist with State and Federal Regulatory reporting of contracts and provider network. Supervise daily functions of Contracts Coordinator staff.

To develop, implement, improve, and manage assigned programs. In addition to the Program Manager II duties, the Senior Program Manager is a leadership role, has a higher level of education/experience, more autonomy, exercises independent judgment, and provides coaching and guidance to less experienced program managers. 

The EDI Analyst is accountable for developing best business practice knowledge and supporting the business in integrating into the EDI solutions (standards and non-standard EDI systems). The EDI Analyst will also be assisting EDI team in maintaining and running processes/jobs for electronic claims and other EDI transactions which include working with external trading partners, transferring data through secure channels, loading the data to the production environment, and testing files from new providers/trading partners.

The Medicare Program Director, reporting to the Chief Strategy and Governments Affairs Officer, is responsible for plan management and informing operations of Partnership’s Medicare dual special needs plan (D-SNP). This position provides direction to health plan departments to ensure compliance with regulatory agencies such as the Centers for Medicare and Medicaid (CMS) and maintains working knowledge of health plan obligations of other regulators including Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC). Responsible for leading strategic initiatives and projects, ensures deliverables are on time and in alignment with strategic initiatives, and in doing so, supports continuity of...

To initiate and coordinate a multidisciplinary team approach to case management. Engages the member/member’s representative in a care plan that assists the member in meeting his/her health and wellness goals. Collaborates, assesses, plans, facilitates, evaluates, and advocates to meet the comprehensive medical, behavioral, and psychosocial needs of the member, while promoting quality and cost-effective outcomes.

The Configuration Analyst provides both operational support to, and analysis of, lower complexity Configuration-related activities. The Configuration Analyst creates, updates, tests and maintains system configuration to support all benefit designs and ensure successful configuration, integration, and accurate and timely payment of claims and all PHC systems. Coordinates testing, quality assurance, configuration, installation, and support to ensure smooth, stable and timely implementation of technology solutions, considering all the areas that a change may impact in the current benefit setup and determine the most appropriate way to implement the change (e.g., research and...

Oversees the day-to-day operations of Partnership HealthPlan of California’s (PHC) Program Integrity Unit. Responsible for ensuring the timeliness of investigations related to potential or actual HIPAA and fraud, waste, and abuse. Supports training, provides direction to the Regulatory Affairs and Compliance (RAC) staff, and serves as an effective liaison for the organization and its internal and external community. 

To establish and maintain excellent relationships with the provider network in a specific geographic region, including healthcare practitioners, office staff, and administrators. Works closely to identify and resolve complex issues, provides education and staff training. Provides service and education via onsite visits and telephone. Assists providers with understanding Partnership HealthPlan of California's policies and procedures and assists with resolving issues that arise.

To direct and coordinate medically necessary behavioral health treatment services for members seeking behavioral health services. Oversees operations of Behavioral Health Call Center and staffing. Oversees staff to ensure the coordination of care for members seeking behavioral health services for both carved in and carved out services. Ensures regulatory compliance with call center performance requirements.