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. 

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

The Manager of Medicare Marketing and Sales will oversee the development and execution of Partnership’s Medicare D-SNP marketing and sales strategy focused on driving smart and measurable growth. The Marketing manager will lead a team that collaborates with Partnership leadership to understand the unique opportunities within each market and deliver on sales and retention goals.

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.

Train examiner and customer service level I staff on all related claim types for all Partnership lines of business using AMISYS Advance system and Claims Operating Instruction Memorandums.