To plan, organize, manage, and implement projects.

Represents PHC 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, and PHC best practices. Works independently, provides leadership on each investigation, prioritizes case deliverables, remains customer-focused, and stays current on changes in the healthcare system that may trigger member dissatisfaction.

Under the direction of the Utilization Management (UM) Supervisor or above, this position will conduct audits of assigned areas, assist in department audit initiatives as well as perform audits in accordance with the department audit plan. As an integral member of the Training and Development Team, this position will help the audit function keep pace with the audit needs of the UM Department.

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...

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...

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.

The Director of EDI Development is responsible for evaluating design, development, and coordination of EDI projects and applications. Responsibilities include designing, coding, testing, and implementing each of the federal/state mandated electronic transactions and other applications; managing EDI developers and operations staff; and ensuring proper design principles and coding techniques are within the industry standards. Working closely with IT management and other department staff, performs requirements gathering, business and operational analysis related to EDI applications, and...

Responsible for overseeing the Configuration and system changes for the claims adjudication and case management systems. Responsible for maintenance and enhancement of system configuration and related database tables, documentation and support of Partnership Health Plan of California’s (Partnership) EDI related functions, testing and assisting in documentation of changes to the system software configuration using a variety of computer software packages to meet Partnership needs. Maintains the...

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...

The Manager of Care Coordination (CC) will lead and support the department leadership in the development, implementation and evaluation of Partnership’s clinical case management services. Collaborates with Supervisor(s) to oversee the department activities and provides guidance to manage these functions to enhance cost effectiveness, ensure compliance with applicable state and federal regulations, and to fulfill all contractual requirements.

The Care Coordination Business Analyst will design, produce, and analyze Care Coordination Department operational data in support of department objectives and goals. Works closely with business users and Configuration to write business requirements, test plans, implementation plans, and other project documentation. Utilize knowledge of numerous applications, databases, information systems, statistical tools and analytical principles to monitor and analyze information related to department operations. May assist Care Coordination Senior Program Manager on more complex projects.

Under guidance from the CC Manager of Regulatory Performance, the Clinical Advisor is 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) and/or regulatory changes and supports leaders with the research, planning, implementation and/or operational readiness submissions across the organization. The Clinical Advisor may support new and ongoing training and staff support needs within the Care Coordination department through the translation...

The incumbent utilizes clinical judgement in providing utilization management services.  The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary.  Assists in determining appropriateness, quality and medical necessity of treatment plans using pre-established guidelines.  This position may be assigned cases in long-term care and ancillary, DME or medical services.

The incumbent utilizes clinical judgement in providing utilization management services.  The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary.  Assists in determining appropriateness, quality and medical necessity of treatment plans using pre-established guidelines.  This position may be assigned cases in long-term care and ancillary, DME or medical services.

The incumbent utilizes clinical judgement in providing utilization management services.  The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary.  Assists in determining appropriateness, quality and medical necessity of treatment plans using pre-established guidelines.  This position may be assigned cases in long-term care and ancillary, DME or medical services.

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.

To maintain accurate provider information by entering all necessary data elements into several database systems. Reviews forms for completeness and researches discrepancies. Ensures all information is updated timely within departmental standards. Responds to routine provider telephone inquiries via telephone and email.

Under the direction of the Sr. Internal Auditor, this position is responsible for leading, and supervising the HealthPlan’s Cost Avoidance and Recoveries Team. Monitors and audits any payment that may be outside the HealthPlan’s current provider contracts or State contract. Identifies overpayments for recovery; researches and adjusts provider refund checks; identifies, verifies, and updates core claims system with members’ other health insurance coverage information; and performs post-payment audit functions in collaboration with Internal Audit.

Primary duty of the CSR III is to routinely process CIFs. They will be responsible to learn all CIF claim types within 18 months of accepting position.

To design, develop, and test client server and web applications at PHC. To work with the Director of Web Applications Development in the design, development, testing, and deployment of web and desktop applications. Works closely with IT staff in developing applications for business needs supporting AMISYS Advance and networked systems. The Senior Web Applications Developer is responsible for designing, developing, testing, and supporting Web Applications.