Job Listings

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 plan, implement, and analyze lifestyle-change program activities to members of Partnership Healthplan. Support participants, provide guidance, and lead members to develop sustainable healthy lifestyles. On behalf of Partnership Healthplan, engages members individually in groups and through multiple modalities that may include telephonic, web-based tools, and through participation in community events.

To engage with community-based organizations, providers, school districts, and other external agencies in order to understand the services and support systems available within the community, facilitate collaboration and alignment between Partnership HealthPlan of California (PHC) and community efforts, and to identify gaps in needed services for the wellness needs of PHC’s population.

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.

Leads the design of the training program for the Provider Relations (PR) Department’s provider demographic database and the provider data master (PDM) system in consultation with PR Supervisors and Managers. Develops training materials and guides. Trains new PR staff and facilitates ongoing training. Performs auditing activities and recommends training topics for staff based on audit results. Performs all activities related to auditing, tracking, and documenting staff performance of operational processes with an emphasis on ensuring provider data and other work output is accurate. Produces audit reports to identify trends for training opportunities.

Represents PHC 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, and PHC best practices. Works independently, provides leadership on each investigation, prioritizes case deliverables, remains customer-focused, and stays current on changes in the healthcare system that may trigger member dissatisfaction.

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 plan, organize, manage, and implement projects.

To respond to member and provider issues and inquiries. Ensures that callers’ questions and/or problems are resolved or are directed to the appropriate person for resolution and provides the highest level of customer service.

Implements PHC Communications strategies through impactful community relations, member engagement, digital engagement media relations, legislative affairs, branding, and communications with other PHC stakeholders.

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.

Represents PHC 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, and PHC best practices. Works independently, provides leadership on each investigation, prioritizes case deliverables, remains customer-focused, and stays current on changes in the healthcare system that may trigger member dissatisfaction.

To plan, organize, manage, and implement projects.

Provides advice and counsel to operational departments. As requested,coordinates certain outside legal counsel and oversees outside counsel contracts.

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.

Identify member non-medical needs and provide psychosocial case management for assigned demographic (i.e., adults or pediatric population). The Social Worker provides members and/or their families with the supports needed to cope with chronic, acute and/or terminal illnesses, often complicated by other social/environmental or historical factors. The SW provides services including but not limited to: - Identification of available public and private resources - Education regarding systems of care - Coordination of care across agencies, the care continuum, and life stages - Education regarding public and private benefits

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.

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.

Oversees the day-to-day recruitment and selection of qualified candidates for Partnership HealthPlan of California (PHC). Partners with management to effectively address recruiting needs in a timely manner. Professionally represents PHC in frequent interactions with applicants, all levels of staff, and the public. Provides leadership, support, and training to assigned staff.