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

The EDI Application Administrator is responsible for the installation, configuration, maintenance, and support of EDI software applications within the organization. This role ensures the optimal performance, availability, and security of applications to meet business needs and user requirements.

The Manager of IT Change Control at Partnership HealthPlan of California (Partnership) plays a critical role in managing and improving the IT change management processes. The role ensures that changes to IT systems, infrastructure, and applications are implemented in a controlled, compliant, and efficient manner to minimize risks and service disruptions to Partnership’s business operations. The Manager of IT Change Control collaborates closely with multiple departments, including IT, security, clinical operations, and external vendors, to ensure changes align with Partnership’s business priorities, regulatory requirements, and industry standards. This role is pivotal in supporting continuous improvement efforts in IT...

The Manager of Telecom will oversee the installation, configuration, management, and troubleshooting of Cisco Unified Communications solutions to all of the health-plan’s contact center organizations (Member Services, Health Services, Claims, PR, and Admin) in the areas of operations, system enhancement & configuration, report generation, knowledge management, and training. This role involves maintaining a robust and secure UC environment, providing enduser support, and ensuring system uptime to deliver seamless communication for our organization.

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 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 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 plan, organize, manage, and implement projects.

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...

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.

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.