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

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 support the Claims Department in maintaining pended claims and claim adjustments within established guidelines. Reviews and processes complex claims, and supports claims examining.

To plan, organize, manage, and implement projects.

To research and resolve provider telephone and written inquiries within established time frames, accurately screen claims, and participate in provider meetings and projects. To accurately research and process paper and electronic medical, outpatient, ancillary, long term care, CHDP, encounter data and paper crossover/other coverage claims within established time frames, applying appropriate program policies related to claims processing and analysis.

To research and resolve provider telephone and written inquiries within established time frames, accurately screen claims, and participate in provider meetings and projects. To accurately research and process paper and electronic medical, outpatient, ancillary, long term care, CHDP, encounter data and paper crossover/other coverage claims within established time frames, applying appropriate program policies related to claims processing and analysis.

To provide organizational and technical support for the analysis, design, configuration, and documentation of Partnership’s computer systems, and technical and problem resolution support to the systems user community. The Senior IT Business Analyst addresses complex systems issues and may work with technical leads and business users to resolve issues; works with business users to gather requirements and recommends a solution, including new systems and functionality; may provide training to business users and IT personnel; and provides coaching and guidance to IT Business Analysts. This position may function independently and applies depth of experience gained from previous successful...

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 provide daily supervision of utilization management staff. Provide departmental leadership, support, resources and direction to staff. Assists in developing and maintaining a cohesive team with a high level of productivity, accuracy and quality to achieve departmental goals and objectives.

To process TARs for selected services using specific procedures and protocol and to provide administrative assistance to UM Coordinators and Leadership staff as assigned. Serves as Systems Trainer for all new hires and provides ongoing education for all HS/UM staff.

To work with a dedicated and committed team, the RN Quality Investigator I is responsible for assessing and improving the quality of care provided by the providers serving our members.

To plan, manage and evaluate clinical department and/or Partnership delegate(s) performance and compliance under DHCS and NCQA regulations. Responsibilities include annual DHCS Medical Audits for Care Coordination, delegation oversight and monitoring activities for applicable providers and entities, and on-going stewardship of NCQA activities to support Partnership’s continued

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

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.

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.

System Administrator  Commission on Medical Care (DBA Partnership HealthPlan of California) is recruiting for our Fairfield, CA office: System Administrator: Monitor and maintain the performance, availability and security of server environments. Conduct daily system health checks, manage backups and ensure recovery procedures are functioning as intended. Manage user accounts, applying system updates, and performing configuration...

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

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

The Senior IT Project Manager is responsible for the successful delivery of large-scale, complex projects often involving multiple internal and external stakeholders through all phases of the SDLC. The Senior IT Project Manager helps set and follow clear project management standards including project plans, change controls, risk management, and other project management documents on given strategic initiatives. The Senior IT Project Manager assists in developing standards, managing the enterprise IT project priority list with IT Directors, and assists in IT Steering Committee meetings if needed. This position reports to the Director of IT Strategic...