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 develop, implement, improve, and manage assigned programs. In addition to the Program Manager I duties, the Program Manager II has a higher level of experience, more autonomy, exercises independent judgement, and conducts business analysis and program analytics. 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. Develops and delivers program goals, measures, and reports.

To effectively lead assigned projects, utilizing appropriate project management methodologies to drive the planning, implementation, and tracking of projects through all aspects of the project lifecycle. Project Managers are responsible for the planning, procurement, and execution of a project. 

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 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 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 the direction of the Director of Quality and Performance Improvement (QI/PI), the Senior Manager of Performance Improvement is responsible for key initiatives within the QI/PI Department: the Partnership Improvement Academy and its associated programs; strategic, organization-wide, and region-specific improvement initiatives; focused quality improvement projects; internal (Partnership staff/departments) quality improvement consultation and training, specifically related to integrating improvement strategies key to Partnership’s Medicare Dual Special Needs Plan (D-SNP) in concert with those already established under Partnership’s long standing Medi-Cal business line; primary liaison to DHCS Quality for mandated Performance Improvement...

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 establish and maintain excellent relationships with the transportation provider network. Identifies service gaps and recruits new transportation providers to increase network adequacy. Works closely to identify and resolve complex issues, provides education and staff training to transportation providers and healthcare providers with members experiencing transportation access issues. Assists providers with understanding Partnership HealthPlan of California's transportation-related policies and procedures and assists with resolving issues that arise.

To plan, organize, manage, and implement projects.

To plan, organize, manage, and implement projects.

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 Database Administrator (DBA) is responsible for the installation, configuration, upgrade, administration, monitoring, and maintenance of all Oracle and SQL databases within the PHC infrastructure. This also includes the development and design of database strategies, monitoring and improving database performance and capacity, and planning for future expansion. The DBA will also plan, co-ordinate and implement security measures to safeguard the database contents.

To support and/or lead in planning, organization, management, and implementation of projects. In addition to the Project Coordinator I duties, a Project Coordinator II has a higher level of experience, works well with ambiguity and is expected to work with more autonomy on assignments 

To develop provider and member educational opportunities for internal departments, external agencies, training, and materials to support PHC providers, community partners, and members. Provides hands-on support to internal team as well as to PHC providers, community partners, and members.

    To provide administrative support to the department head, leadership teams, and staff as assigned. In addition to the Administrative Assistant I duties, the Administrative Assistant II has a higher level of experience and more autonomy, is involved in project coordination, identifies necessary efficiencies, and is exposed to confidential information.

To provide Basic Population Health Management services for members which includes engaging with members individually or as part of a group to support lifestyle modifications to manage chronic diseases, to identify care gaps and needed services, and to aid Partnership members in maintaining wellness. Healthy Living Coaches shall also serve as a resource about Partnership member benefits as well as Population Health programs and services.

The Policy Analyst will be 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....

To respond to member and provider calls regarding Plan policies, procedures, membership, eligibility, benefits, and claims, providing the highest level of customer service. In addition to the Member Services Representative duties, the Lead Member Services Representative has a higher level of experience, monitors call queues, assists with training material, and handles complex calls that cannot be resolved by the Member Services Representatives.

To plan, organize, manage, and implement projects.