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 Director of EDI Development is responsible for evaluating design, development, and coordination of EDI projects and applications. Responsibilities include designing, coding, testing, and implementing each of the federal/state mandated electronic transactions and other applications; managing EDI developers and operations staff; and ensuring proper design principles and coding techniques are within the industry standards. Working closely with IT management and other department staff, performs requirements gathering, business and operational analysis related to EDI applications, and...

The Manager of Care Coordination (CC) will lead and support the department leadership in the development, implementation and evaluation of Partnership’s clinical case management services. Collaborates with Supervisor(s) to oversee the 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.

The Care Coordination Business Analyst will design, produce, and analyze Care Coordination Department operational data in support of department objectives and goals. Works closely with business users and Configuration to write business requirements, test plans, implementation plans, and other project documentation. Utilize knowledge of numerous applications, databases, information systems, statistical tools and analytical principles to monitor and analyze information related to department operations. May assist Care Coordination Senior Program Manager on more complex projects.

Under guidance from the CC Manager of Regulatory Performance, the Clinical Advisor is responsible for drafting, editing, reviewing, auditing, tracking, monitoring and maintaining policies and procedures for Partnership HealthPlan of California. Alongside designated organizational leadership ensures compliance with governing rules, regulations, and/or accreditation standards. Reviews both draft and final All Plan Letters (APLs) and/or regulatory changes and supports leaders with the research, planning, implementation and/or operational readiness submissions across the organization. The Clinical Advisor may support new and ongoing training and staff support needs within the Care Coordination department through the translation...

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 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.

The Manager of Utilization Management (UM) will provide leadership and clinical oversight for operational aspects of UM, including the responsibility for providing daily oversight, leadership, support and management of assigned staff. Collaborates with Supervisor(s) to oversee the 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.

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 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.

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.

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 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.