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.

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.

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

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.

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.

Primary duty of the CSR III is to routinely process CIFs. They will be responsible to learn all CIF claim types within 18 months of accepting position.

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.

Provide supervisory oversight during the daily operations of the outpatient review process. Supervise and train assigned team members. Provide leadership, support, resources, and direction to staff. Assist in determining appropriateness, quality, and medical necessity of requested service.

To assist in the improvement of PHC’s Health Services business processes and systems through the identification, analysis, and recommend actions for improvement. Provides systems support of operating and business goals of the health plan as a whole. This position collaborates with the Finance, Information Technology (IT) and Data Warehouse (DW) teams to develop and support organization-wide reporting. The incumbent participates in gathering and documenting report requirements. Responsible for designing, building and administering reporting solutions for requesting departments. Assists departmental Business/Data Analysts in developing reports using the available Business Intelligence (BI) tools. Will develop ad-hoc reports for business users as applicable. Participates in the design and development of the reporting infrastructure using SQL Server technologies and BI reporting tools (Tableau, SAS, Business Objects).  

To provide organizational and technical support for the analysis, design, configuration, and documentation of PHC’s computer systems, and technical and problem resolution support to the systems user community. The Senior IT Business Analyst addresses complex systems issues and may work with technical leads and business users to resolve issues; works with business users to gather requirements and recommends a solution, including new systems and functionality; may provide training to business users and IT personnel; and provides coaching and guidance to IT Business Analysts. This position may function independently and applies depth of experience gained from previous successful assignments.

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 Improvement training team, and will facilitate workshops and learning collaborative sessions on topics such as improvement methodology, QI measurement, process improvement, project management, and change management.

To oversee active project management and deliver successful projects. Sets and follows clear project management standards including project plans, risk registers, and other project management documents. Responsible for the successful delivery of IT projects and assists in developing standards, managing the enterprise IT project priority list, and IT Steering Committee meetings.