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

The Training and Education Coordinator will design the training program for the Utilization Management (UM) Department’s data platforms, medical necessity software, and department policies and procedures in consultation with UM Supervisors and Managers

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 develops forms and presentations.

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 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.

This position is responsible for working directly with local First Five Commissions and agencies and providers who work directly with children, in Partnership HealthPlan of California (Partnership) assigned counties. The goal of this position is to ensure youth obtain the health services they are entitled to and that services are closely coordinated with other services. This position will assist in the design, implementation, and/or expansion of strategic programs and departmental initiatives in relation to this population and regulatory deliverables. Develops and delivers program goals, measures, and reports. This position will be responsible for a range of systems to strengthen coordination and supports for children and youth...

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.

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 review Treatment Authorization Requests (TARS)/Coverage Determination Form (CDF) to promote safe, appropriate, and cost-effective drug therapy. Communicates and educates prescribers and dispensing pharmacies on TAR process, TAR determination, and PHC formulary. Participates in P&T meetings and formulary management.

The Security Engineer will play a critical role in advancing the organization’s overall security maturity by continuously evaluating and improving the organization’s security framework, ensuring alignment with industry’s best practices, and driving initiatives that reduce risk and enhance the security posture across the organization. This role is critical in safeguarding the organization’s data, applications, and systems by designing, implementing, and managing advanced security solutions. The Security Engineer will focus on security posture, vulnerability discovery and remediation, protections, CVE monitoring, vendor security, and will collaborate with cross-functional teams to enhance security practices,...

The Sr. IT Manager of Enterprise Applications - Claims System will oversee and manage HRP Transaction Management functions effectively. This entails leading a team, prioritizing tasks, establishing and enforcing standards, training staff, testing and implementing new code, analyzing user requirements, and aligning work with business priorities.

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 Provider Payment Strategy Manager, this position will support the development, evaluation, and advancement of provider reimbursement methodologies to align with organizational strategies and objectives, including performance and alternative payment approaches, and advise executive-level leadership regarding the feasibility of various strategies. This position will require the utilization of a variety of methods, models, and data sources to evaluate potential reimbursement methodologies and rates, will provide organizational education related to Partnership’s network provider reimbursement, support the development and implementation of business unit policies and procedures, and perform other duties...

The Manager of Medicare Marketing and Sales will oversee the development and execution of Partnership’s Medicare D-SNP marketing and sales strategy focused on driving smart and measurable growth. The Marketing manager will lead a team that collaborates with Partnership leadership to understand the unique opportunities within each market and deliver on sales and retention goals.

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.

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...

Daily supervision of the Data Coordinator/UM staff to ensure the highest level of customer service to the medical providers of the community.

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 design, develop, and test client server and web applications at PHC. To work with the Director of Web Applications Development in the design, development, testing, and deployment of web and desktop applications. Works closely with IT staff in developing applications for business needs supporting AMISYS Advance and networked systems. The Senior Web Applications Developer is responsible for designing, developing, testing, and supporting Web Applications.