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.

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 provide daily supervision of utilization management staff. Provide departmental leadership, support, resources and direction to staff. Assists in developing and maintaining a cohesive team with a high level of productivity, accuracy and quality to achieve departmental goals and objectives.

The Human Resources Leave and Accommodation Administrator serves as the primary point of contact and subject matter expert for employee leave and accommodation matters. This role guides employees and managers through the leave and accommodation processes, ensures an efficient and supportive experience, and maintains strict compliance with all applicable federal and state

Under the general direction of the CIO, the Director, IT Strategic Initiatives is responsible for overseeing IT strategic initiatives; developing, implementing, and auditing methodologies and best practices related to steering committees; and prioritization of projects and best practices related to the Systems Development Life Cycle (SDLC). The Director will be responsible for ensuring that there is a consistent development and implementation process and that it is followed. The Director will work with the CIO and other department directors to prioritize projects and provide status reports to the CIO and Steering Committee.

To begin Treatment Authorization Requests (TAR) reviews and perform data entry upon TAR determination by pharmacy staff. Performs eligibility and benefit investigations. Supports pharmacy department with extracting and collecting data for reporting needs. Supports department's administrative needs, and participates in special projects as assigned by pharmacy technician lead, supervisor, and departmental staff.

In collaboration with Care Coordination team members, this position provides support and guidance to HealthPlan members referred to the Care Coordination Department for Case Management services and programs. The Health Care Guide I works closely with members, families, providers, community agencies, and the interdisciplinary care team to assist in coordination of benefits in a timely and cost-effective manner, while connecting members to available internal and external resources.

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

The IT Data Quality Analyst supports the development and execution of IT data quality processes across IT teams and functions. Under guidance from senior staff, this role assists in identifying IT data quality gaps, performs data profiling and analysis, and helps maintain processes that ensure organizational data is accurate, complete, and compliant. The analyst works collaboratively across IT and operational teams to investigate data issues and contribute to ongoing IT data quality improvement efforts.

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.

Responsible for the delivery of business intelligence solutions across the enterprise. Manages deployment, maintenance, and support of data access tools and reports.

In collaboration with departmental and organizational leadership, supports the organization’s community reinvestment activities through active and meaningful engagement in identified community workgroup and initiatives. On behalf of the health plan identifies and supports, key strategic activities and interventions that support alignment of collective agency efforts that promote and support efforts to encourage member disparity health outcomes.

The Regulatory Affairs Specialist II has demonstrated competencies in supporting the plan-wide regulatory affairs and compliance program, including activities related t

To oversee the appropriateness and quality of care delivered through Partnership HealthPlan of California and for the cost-effective utilization of services.

In collaboration with Care Coordination team members, this position provides support and guidance to HealthPlan members referred to the Care Coordination Department for Case Management services and programs. The Health Care Guide I works closely with members, families, providers, community agencies, and the interdisciplinary care team to assist in coordination of benefits in a timely and cost-effective manner, while connecting members to available internal and external resources.

Represents Partnership 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,

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.

In collaboration with the HR Recruiters coordinates the ongoing recruitment and selection of industry experienced and leadership positions for Partnership HealthPlan of California (PHC) by providing assistance and administrative support. Professionally represents Partnership in frequent interactions with applicants, all levels of staff, and the public. Holds employee and applicant

The Senior Data Analytics and Reporting Developer serves as a technical leader in the design, development, and optimization of enterprise-level data reporting solutions. This role is responsible for architecting advanced dashboards, automated reporting pipelines, and analytical models that empower strategic decision-making across the organization. The Senior Developer collaborates with business leaders, drives best practices, mentors team members, and ensures data quality, scalability, and performance across reporting systems.

Supervise daily operations and provide leadership, support, and direction to assigned Provider Relations Representative staff. Ensure the highest level of customer service is a priority of PR staff. Monitor department goals and meet deadlines. Recruit and retain Provider network.