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 maintain accurate provider information by entering all necessary data elements into several database systems. Reviews forms for completeness and researches discrepancies. Ensures all information is updated timely within departmental standards. Responds to routine provider telephone inquiries via telephone and email.

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

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

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

Under the direction of the Organizational Development Manager, this position: designs and develops innovative and engaging eLearning and Instructor-Led Training (ILT) courses; administers training courses to Partnership HealthPlan of California (PHC) staff; and performs other duties as assigned.

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.

Under the direction of the Sr. Internal Audit or above will conduct audits of assigned areas, assist in the internal audit initiatives as well as perform audits in accordance with the annual audit plan. As an integral member of the Internal Audit team, help the audit function keep pace with the audit needs of the organization. Applies industry standard audit procedures and documents findings in

Under the direction of the Sr. Internal Auditor or above will conduct audits of assigned areas, assist in the internal audit initiatives as well as perform audits in accordance with the annual audit plan. As an integral member of the Internal Audit team, help the audit function keep pace with the audit needs of the organization. Applies industry standard audit procedures and documents findings in work papers in accordance with professional standards and internal audit policies and procedures. Assist in identifying weaknesses and gaps in internal controls and elevated risk areas. Participate in drafting and communication of audit recommendations and written reports. Participate in providing...

To review, research, and resolve claims for all Medi-Cal claim types within established production and quality standards, including manual processing. Creates appropriate documentation that reflects the actions taken and status of the claim. Generates provider communication, such as letters. Routes and tracks claims requiring review by other staff and departments, and processes when possible.

Under the direction of the Cost Avoidance Supervisor, the Cost Avoidance Specialist I monitors activities related to cost savings and recoveries of medical claim payments; identifies and verifies members other health coverage (OHI), updates system and recovers overpayment, and researches and validates provider refund checks. The Cost Avoidance Specialist interfaces with all departments in an information sharing capacity to promote proper payment procedures and timely cost effectiveness in claims payments.

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 or specialty care review. May also carry a caseload of cases requiring telephonic and/or on-site inpatient review at acute or rehab facilities.

To provide coordination and administrative support to department managers. Performs a variety of general clerical duties, including data entry, report generation, and develops forms and presentations.

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.

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.

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...

To assist supervisor with daily operations and functions by providing clerical and technical support in areas of data entry and assist providers with issues or questions concerning authorization for services.

To provide daily oversight, leadership, support, training and direction of both clinical and non-clinical staff. Supports and assists the Team Manager in developing and maintaining a cohesive team with a high level of productivity and accuracy to achieve the department's overall performance metrics. Designs and implements high quality, cost-effective care plans to enable members to achieve health goals.

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 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.