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.

The Manager of Utilization Management (UM) will provide leadership and clinical oversight for operational aspects of UM, including the responsibility for providing daily oversight, leadership, support and management of assigned staff. 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.

To provide administrative support to the department head, leadership team, and staff as assigned.

The Training and Education Coordinator will design the training program for the Utilization Management (UM) Department’s data platforms, medical necessity software, and department policies and procedures in consultation with UM Supervisors and Managers

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.

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.

This position is responsible for working directly with local First Five Commissions and agencies and providers who work directly with children, in Partnership HealthPlan of California (Partnership) assigned counties. The goal of this position is to ensure youth obtain the health services they are entitled to and that services are closely coordinated with other services. This position will assist in the design, implementation, and/or expansion of strategic programs and departmental initiatives in relation to this population and regulatory deliverables. Develops and delivers program goals, measures, and reports. This position will be responsible for a range of systems to strengthen coordination and supports for children and youth...

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.

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.