To research and resolve provider telephone and written inquiries within established timeframes, accurately screen claims, and participate in provider meetings and projects. Support for either escalated calls or to accept calls of a more complex nature requiring additional skills. To provide support to CSR staff when call volume requires additional personnel. Routinely process CIFs as part of their daily workload.

The Coordinator II will coordinate assigned departmental projects and provide complex administrative support to department leaders. Develops, implements and monitors processes, tools, and systems for collecting, tracking and managing information required for monitoring performance and deadlines. Develops and produces reports. In addition to the Coordinator I duties, the Coordinator II may handle escalated calls, escalated Helpdesk inquiries, and may follow up with providers regarding missing documentation. 

The Supervisor of Configuration provides frontline leadership and oversight of configuration and system change activities supporting claims adjudication, case management, and related health plan systems relevant to the assigned area(s) of responsibility within the Configuration Department. This role is responsible for supervising the day-to-day execution of configuration work, ensuring accuracy, compliance, and adherence to established governance standards. The Supervisor maintains the accuracy and completeness of configuration projects and programs in alignment with organizational policies, contract regulations, and State of California Medi-Cal requirements, while supporting implementation, testing, and coordination of system...

Represents Partnership 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,

The Policy Analyst will be 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)

To research and resolve provider telephone and written inquiries within established timeframes, accurately screen claims, and participate in provider meetings and projects. Support for either escalated calls or to accept calls of a more complex nature requiring additional skills. To provide support to CSR staff when call volume requires additional personnel. Routinely process CIFs as part of their daily workload.

To provide coordination and implementation support of defined tasks for the assigned program(s).

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 respond to member and provider issues and inquiries. Ensures that callers’ questions and/or problems are resolved or are directed to the appropriate person for resolution and provides the highest level of customer service.

To begin Treatment Authorization Requests (TAR) reviews and perform data entry upon TAR receipt or determination by pharmacy staff. Performs eligibility and benefit investigations. Supports pharmacy department with extracting and collecting data for reporting needs. Supports department's administrative needs and participates in special projects as assigned by pharmacy technician lead, supervisor, and departmental staff.

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.

To effectively lead assigned projects, utilizing appropriate project management methodologies 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.

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.

Under direction from the Director of Utilization Management, manages and provides direction to the Health Services department Managers for all product lines ensuring consistent development, implementation, and maintenance of health services programs and achievement of department goals and objectives, in a fast paced, ambiguous environment. Ensures compliance with established criteria and Partnership benefits. 

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.

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.

Train examiner and customer service level I staff on all related claim types for all Partnership lines of business using AMISYS Advance system and Claims Operating Instruction Memorandums.