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.

Perform routine and ad-hoc reporting and data management for internal and external users; assist in maintaining reporting systems within the department. To prepare, analyze, report, and manage data used for both plan-wide and regional decision making for evaluating performance in key quality measures and the effective use of health plan resources on a routine and ad hoc basis. Works collaboratively with departments company-wide to identify data needs, develop and maintain data queries and tools, and complete accurate...

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 

Under the direction of the Associate Director of Internal Audit or above, the Cost Avoidance Manager is responsible for building, leading, and managing the HealthPlan’s Cost Avoidance and Recovery Teams. The purpose of the Cost Avoidance Team is to monitor payment of claims. The purpose of the Recovery Team is to identify overpayments for recovery; research and post provider refund checks, monitor receivables in the Core System; identify, verify, and update Core System with members’ other health insurance coverage information as required.

Under the general direction of the Associate Director of Health Analytics, this position is responsible for managing the Health Analytics Team at PHC. The goal of the Health Analytics Team is to help PHC improve the health of our members and the communities we serve by developing and producing high quality analytic reports of health care data for use internally and externally. To achieve this, the Manager of Health Analytics will manage, mentor, and train a group of highly motivated and highly qualified health analysts, working collaboratively with the Data Warehouse Team and the Financial Analysis Team. Collectively these three units (Health Analytics, Financial Analysis, and Data Warehouse) provide the analyst workforce and...

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.

The Senior Healthcare Data Analyst I contributes to the overall success of the organization by developing analytic solutions that support activities related to health services utilization management, care coordination, quality improvement and population health. Through analyzing patient claims, member enrollment, and other data, the Senior Healthcare Data Analyst

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 design, support, and provide strategic planning of the Business Intelligence solution across the enterprise. Manages deployment, maintenance, and support of Business Intelligence tools and reports. Analyzes, creates, documents, tests, maintains, troubleshoots, and promotes the Business Intelligence environment.

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.

Responsible for the development of all processes necessary to complete all phases of the Enterprise Data Warehouse (EDW). This includes source identification, data collection, data transformation, normalization, rule administration, error detection and correction, data consolidation, data storage, data distribution, schema mapping, data enrichment, and data governance.

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 provide administrative support to the department head, leadership team, and staff as assigned.

This position designs, develops, presents, and/or facilitates innovative and engaging organization-wide Instructor-Led Trainings (ILT), video trainings, and other trainings as requested. Works with department Subject Matter Experts (SMEs) on designing and/or standardizing targeted trainings (i.e. – department specific or audience specific trainings) as requested.

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.

The Human Resource (HR) Analyst will collect, compile, and analyze HR data, metrics, andstatistics, and apply this data to assist HR leadership in developing strategic solutions and data driven decisions. Applies best practice data analytic skills to guide decision-making, process improvement and a desire to bring analytical solutions to organization's HR strategies. Supports the organization's overall ability to use Human Resource data in decision making to drive improved outcomes by supporting key initiatives with data analysis and insight...

To assist in the day-to-day operations and management of the Member Services Department. Provides leadership and support and direction to Member Services staff.

This position provides support and guidance to Partnership HealthPlan of California (PHC) members for wellness services and incentive programs in a call-center environment. The Wellness Guide works closely with members and their families to encourage members to engage in healthy activities (including preventative care visits and chronic care management), remind members of available benefits, and connect members to available internal and external resources.

To accurately perform concurrent, retrospective, and special audits on all level I claim types for all PHC lines of business.

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