Provide a range of social work services in collaboration with PHC staff to meet the psycho-social and care coordination needs of members. Responsible for the assessment and care coordination of the psycho-social needs of members, families and/or caregivers to help promote positive coping skills, reduce the risk of premature institutionalization, assist individuals in maintaining independence in the community and increase stabilization of social determinants.

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.

Under the direction of the Manager of Performance Improvement, the Improvement Advisor is uniquely positioned to drive improvement across PHC, our provider network, and the communities we serve. The Improvement Advisor will work internally and externally with provider practices and community partners to identify, plan, and facilitate quality improvement projects. Via individualized facilitation, this position will coach and train improvement teams to build team members’ quality improvement (QI) skills, develop their organizational capacity for QI work, and help them meet their specific QI goals. In addition to working directly with improvement teams, the Improvement Advisor will join PHC’s Performance...

The Quality Data Validation Analyst is responsible for improving the quality and completeness of data used for Partnership’s Healthcare Effectiveness Data Information Set (HEDIS) reporting initiative. This position will focus on sets of measures required by federal and state regulatory bodies and collaborates with internal and external stakeholders to improve the exchange of clinical data that meets the requirements for use in the reporting and ensures that services completed within Partnership’s provider network are accurately leveraged in the HEDIS Project. This position is a key stakeholder on Partnership’s implementation of a Data Aggregator vendor solution and will partner with the vendor and internal...

 Responsible for developing, contracting, implementing, and maintaining new and existing provider networks. Manage and monitor contractual relationships with existing PHC contracted providers. Assist with State and Federal Regulatory reporting of contracts and provider network. Supervise daily functions of Contracts Coordinator staff.

The EDI Analyst is accountable for developing best business practice knowledge and supporting the business in integrating into the EDI solutions (standards and non-standard EDI systems). The EDI Analyst will also be assisting EDI team in maintaining and running processes/jobs for electronic claims and other EDI transactions which include working with external trading partners, transferring data through secure channels, loading the data to the production environment, and testing files from new providers/trading partners.

The Medicare Program Director, reporting to the Chief Strategy and Governments Affairs Officer, is responsible for plan management and informing operations of Partnership’s Medicare dual special needs plan (D-SNP). This position provides direction to health plan departments to ensure compliance with regulatory agencies such as the Centers for Medicare and Medicaid (CMS) and maintains working knowledge of health plan obligations of other regulators including Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC). Responsible for leading strategic initiatives and projects, ensures deliverables are on time and in alignment with strategic initiatives, and in doing so, supports continuity of...

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.

Oversees the day-to-day operations of Partnership HealthPlan of California’s (PHC) Program Integrity Unit. Responsible for ensuring the timeliness of investigations related to potential or actual HIPAA and fraud, waste, and abuse. Supports training, provides direction to the Regulatory Affairs and Compliance (RAC) staff, and serves as an effective liaison for the organization and its internal and external community. 

To establish and maintain excellent relationships with the provider network in a specific geographic region, including healthcare practitioners, office staff, and administrators. Works closely to identify and resolve complex issues, provides education and staff training. Provides service and education via onsite visits and telephone. Assists providers with understanding Partnership HealthPlan of California's policies and procedures and assists with resolving issues that arise.

To establish and maintain excellent relationships with the provider network in a specific geographic region, including healthcare practitioners, office staff, and administrators. Works closely to identify and resolve complex issues, provides education and staff training. Provides service and education via onsite visits and telephone. Assists providers with understanding Partnership HealthPlan of California's policies and procedures and assists with resolving issues that arise.

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 Act as a Long Term Services and Supports (LTSS) Provider Liaison-Long Term Care Facilities and Skilled Nursing Facilities (SNF) including the responsibility of collaborating with internal departments to identify process improvement and maintaining consistent knowledge of benefit changes from the Department of Health Care Services.

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

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.

To provide daily oversight, leadership, and support to Behavioral Health Access Guides. Oversees the coordination of medically necessary behavioral health treatment services for adults and children with behavioral health needs.

The Senior Data Scientist I plays a pivotal role in utilizing data to generate insights, applying advanced statistical or machine learning methodologies, solving complex business problems, and influencing decision-making across the organization. This position reports to the Data Science Manager of the Health Analytics unit.

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

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.

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.