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. 

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.

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.

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.

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 Act as a Long Term Services and Supports (LTSS) Provider Liaison-Long Term Care Facilities and Skilled Nursing Facilities (SNF) including the responsibility of collaborating with internal departments to identify process improvement and maintaining consistent knowledge of benefit changes from the Department of Health Care Services.

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

To review Treatment Authorization Requests (TARS)/Coverage Determination Form (CDF) to promote safe, appropriate, and cost-effective drug therapy. Communicates and educates prescribers and dispensing pharmacies on TAR process, TAR determination, and PHC formulary. Participates in P&T meetings and formulary management.

To provide administrative support to the executive leader, leadership teams, and staff as assigned. In addition to the Administrative Assistant II duties, the Executive Assistant has a higher level of education and experience and more autonomy, works with a higher level of internal/external customers, serves as liaison to external customers, and a exposed to higher confidentiality.

To provide daily oversight, leadership, and support to Behavioral Health Access Guides. Oversees the coordination of medically necessary behavioral health treatment services for adults and children with behavioral health needs.

To maintain accurate provider information by entering necessary data elements into several database systems. Works closely with team members and other departments to research and resolve routine and complex issues and inquiries related to provider data. In addition to the Provider Systems Data Specialist I duties, the Provider Systems Data Specialist II has a higher level of experience, more autonomy, and more complex assignments.

The Senior Data Scientist I plays a pivotal role in utilizing data to generate insights, applying advanced statistical or machine learning methodologies, solving complex business problems, and influencing decision-making across the organization. This position reports to the Data Science Manager of the Health Analytics unit.

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

To develop, implement, improve, and manage assigned programs. In addition to the Program Manager I duties, the Program Manager II has a higher level of experience, more autonomy, exercises independent judgement, and conducts business analysis and program analytics. 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. Develops and delivers program goals, measures, and reports.

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.

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.