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. 

To review, research, and resolve claims for all Medi-Cal claim types within established production and quality standards, including manual processing. Completes and processes claims and claims worksheets. Creates appropriate documentation that reflects the actions taken and status of the claim. Generates provider communication, such as letters, as necessary. Routes and tracks claims requiring review by other staff and departments, and processes when possible. Claims Examiner II is distinguished from Claims Examiner I by a higher level of autonomy and experience, as well as an ability to process a wider range of claim types.

Under direction from the Director of Utilization Management, manages and provides direction to the Health Services department Managers for all product lines ensuring consistent development, implementation, and maintenance of health services programs and achievement of department goals and objectives, in a fast paced, ambiguous environment. Ensures compliance with established criteria and Partnership benefits. 

The Internal Auditor is an important position to ensure quality case investigations within the Grievance & Appeals Department (G&A). The auditor assesses the quality of all grievance and appeal cases to ensure they meet DHCS-mandated requirements, NCQA specifications, and Partnership professional standards.  Conducts individual audits of grievance, appeal, exempts, and State Hearing cases completed by the Grievance staff. Identifies and recommends improvements to advance the overall quality of investigation outcomes.

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.

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

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.

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.

The Configuration Quality Assurance Analyst I is responsible for auditing of Configuration Analyst I and Configuration Specialists on system related job functions. Performs retrospective, concurrent, and special configuration audits. Collaborates with Configuration Technical Development and Quality Assurance teams to identify audit trends and staff training.

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.

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.

Under direction of the Facilities Supervisor or above, this position will assist with the coordination of the maintenance and repair of the building, including electrical, carpentry, pest control, and scheduling of other repairs as needed. This position will receive instruction and assistance in new and unusual situations and on Partnership’s policies and procedures. The duties and

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

To research and resolve complex claims issues which cross interdepartmental lines and communicate the outcome to providers and affected Partnership managers. Develops and maintains provider training materials for all lines of business. Conducts provider trainings across Partnership departmental lines in group or individual provider settings. 

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.

To provide high-level support for day-to-day PC operations, production operations support, systems and telecommunications support. Support and lead all help desk functions with PC troubleshooting, performing software updates and maintaining the inventory of PC’s and network systems hardware. Serve as the primary and second level escalation point for desktop, VoIP, A/V, and connectivity support to internal customers/ end-users. Supports IT Operations efforts in the building with implementation, testing, and deployment of new servers, and software, systems, network, and security changes. Primary operations support to production environment, maintains necessary skills related to production support,...

To respond to member and provider inquiries regarding case management telephonically. Ensures that callers’ questions and/or problems are resolved or are directed to the appropriate person for resolution and/or entered as a referral for case management while providing the highest level of customer service.

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 analyze and interpret financial data and procedures to prepare financial information and reports. Applies generally accepted accounting principles and procedures (GAAP) to record, classify, and examine financial transactions. Participates in Month End Close responsibilities such as journal entry creation to book expenses and accruals, uploads these items to accounting system and reconciling sub ledger accounts. Participates in annual financial audit by preparing requested audit schedules and responding to ad hoc audit requests. Responds to customer base (i.e. employees, outside vendors, members) in a timely and professional manner