Job Listings

To provide coordination and administrative support to department managers. Performs a variety of general clerical duties, including data entry, report generation, and develops forms and presentations.

To support the objectives of the regulatory and compliance program and to ensure related activities are in alignment with regulatory requirements, contractual obligations, and ethical standards.

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

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 initiate and coordinate a multidisciplinary team approach to case management. Engages the member/member’s representative in a care plan that assists a 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.

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.

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.

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.

To effectively train, implement, and communicate program management best practices across the organization ensuring accuracy, consistency, and thoroughness. Program Managers are responsible for the planning, communication, ongoing support, and execution of program improvements. Different from the Program Manager II, the Senior Program Manager is a leadership role, has a higher level of education/experience, more autonomy, exercises independent judgment, and provides coaching and guidance to less experienced program managers. Leads program management for cross-functional, internal, external, and complex programs and may directly supervise program roles. Provides day-to-day management of reporting including research, business and financial analysis, problem solving, issue tracking, and resolution.

To manage and coordinate incoming grievances and appeals and provide administrative support for the Grievance Unit. Assesses and completes appropriate documentation for tracking and trending date, which may include conducting all pertinent research on a level one grievance in accordance with all established regulatory guidelines. Reviews delegated grievance logs and processes requests for grievance data and reporting.

Under the direction of the Associate Director of Communications and Public Affairs, the Communications Supervisor is responsible for the development and execution of PHC communication strategies. The Communications Supervisor will proactively advance PHC’s mission, strategic plan, and being a valued neighbor in the communities served by PHC.

To effectively communicate and implement project management methodologies required 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. Projects are time bound with a distinct start and end point. Ensure accuracy, consistency, and thoroughness of projects.

To research and resolve complex claims issues which cross interdepartmental lines and communicate the outcome to providers and affected PHC managers. Develops and maintains provider training materials for all lines of business. Conducts provider trainings across PHC departmental lines in group or individual provider settings.

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.

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 direction of the Senior Manager of Treasury and Internal Audit, the Senior Internal Auditor will assist in developing, implementing, and conducting effective internal audits that support PHC’s financial, operational, process improvement, risk management activities and compliance with policies and procedures for all departments. Providevalue-added advice and support to business partners on the creation or modification of policies, procedures, processes, to ensure an appropriate level of internal control and compliance is maintained.

To provide coordination and administrative support to department managers. Performs a variety of general clerical duties, including data entry, report generation, and develops forms and presentations.

To plan, monitor, and evaluate the delivery of designated Health Services programs and functions for Partnership HealthPlan of California. Collaborates with Supervisor(s) to oversee the day-to- day department activities and provides guidance to manage these functions to enhance cost effectiveness, ensure compliance with applicable state and federal regulations, and to fulfill all contractual requirements.

Under the direction of the Director of Quality and Performance Improvement (QI/PI), the 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 improvement initiatives; - Focused quality improvement projects; - Internal (PHC staff/departments) quality improvement consultation and training.

To lead and participate in the development of complex software systems and programs at PHC. Collaborates with the IT Director in the analysis, design, programming utilizing specifications and applying programming standards, troubleshooting, problem resolution, maintenance, and documentation of software systems and programs. Oversees all aspects of designated application and program support including development, code installation, incident management, problem management, proactive maintenance, problem resolution.