Alameda Alliance for Health jobs in Alameda, CA - 91 jobs

Applicants must be a California resident as of their first day of employment PRINCIPAL RESPONSIBILITIES: Under the general supervision of the Supervisor, IT Applications, the Business Analyst performs complex business process and data analysis with internal customers to gather business requirements for use in identifying innovative technology solutions and supporting system configuration to meet business needs. This position will be the liaison between business and technical teams to provide technical solutions, processes, system configuration and resolutions. Organization expects job performance to be consistent with its vision and mission. Day-to-day work is focused on these key performance areas. Percentages of time are estimates based upon observation in the position. Principal responsibilities include: * Lead work groups in business process analyses to determine the business needs of customers and implement the changes, additions, and improvements that are needed for Business Applications (i.e., Provider repository, quality applications, claims processing, enrollment, capitation) * Identify and analyze various user problems and make appropriate recommendations. Participate in upgrade/replacement/ new implementation projects by tracking activity, resolving problems, publishing progress reports, recommending actions and assisting with the management of vendor relationships. Collaborate with the Manager, Vendor Management as appropriate. * Determine operational objectives by studying business functions, gathering information, evaluating input and output requirements and formats. Improve systems by studying current practices, design modifications. * Configure, analyze, and audit core system current-use functionality and resulting data for best practices. This may include member enrollment, benefits, claims, assessments, authorization rules, correspondence, membership, fee schedules, provider and hospital contracts, as well as other system module configuration. * Recommend technology solutions and manage vendor functionality enhancements to meet the business needs of the AAH Departments. Document those needs and the resulting changes implemented. * Assist with the business case for new and upgrading systems. Conduct cost/benefit analysis. Define project requirements by identifying requirements, project milestones, phases, and elements. Help form project teams and establish project budget. Evaluate and plan systems training for upgrade/replacement/ new implementation projects. * Design, plan and conduct end-user training for a variety of software applications on desktop and laptop computers. * Other duties as assigned. PHYSICAL REQUIREMENTS * Constant and close visual work at desk or on a computer. * Constant sitting and working at desk. * Constant data entry using keyboard and/or mouse. * Frequent use of telephone headset. * Constant verbal and written communication with staff and other business associates by telephone, correspondence, or in person. * Frequent lifting of folders and other objects weighing between 0 and 30 lbs. * Frequent walking and standing. Number of Employees Supervised: 0 MINIMUM QUALIFICATIONS: EDUCATION OR TRAINING EQUIVALENT TO: * Bachelor's Degree or equivalent professional experience. MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE: * Six years of experience in business analysis. * Two years of experience in an operational healthcare or payer setting preferred. Two years of experience in research, analysis and/or business processes required. * Three years working knowledge of process functionality and understanding of business platform(s). SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE): * Ability to create diagrams such as Use Cases, DFD (Data Flow Diagrams), and others. * Knowledge of relational database systems, such as SQL or Microsoft. * Knowledge of the theory, principles, practices and methods of system analysis. * Must be able to handle competing priorities. * Ability for critical thinking and communication is required. * Strong interpersonal skills using clear, concise and professional verbal and written communication skills mandatory, mature judgment, and diplomacy required to interact effectively with a broad spectrum of people, both individually and in groups. * Ability to prioritize daily work tasks. * Ability to exercise initiative and judgment and make decisions within the scope of assigned authority. * Ability to identify sources of problems and arrive at appropriate solutions. * Understanding of complex systems and how they integrate and impact the entire organization. * Experience in defining problems, collecting data, establishing facts, and drawing valid conclusions. SALARY RANGE: $110,094.40- $165,131.20 ANNUALLY The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.

FLSA Status: Non-exempt Department: Community Based Programs Reports To: Manager, SDOH or Manager, Community Based Case Management Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 GENERAL DESCRIPTION OF POSITION The Community Based Services Specialist serves as the lead, primary contact, and liaison for developing, supporting and monitoring the network of public and community based providers and vendors delivering Enhanced Care Management (ECM), Community Supports (CS), and/or other activities, programs or special projects addressing social determinants of health. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. * Develop and maintain updated knowledge of community based services, and capacity across Santa Clara County and support identification and assessment of ECM and/or CS provider network gaps. * Recommend for initial and ongoing needs to support ECM and/or CS delivery system and operational infrastructure including data exchange, workforce training and capacity building. * Support ECM and/or CS authorization and delivery process in accordance with DHCS-developed service definitions, eligibility criteria and reporting requirements. * Oversee the development and management of the ECM, SDOH and/or CS provider network including: * Serve as a knowledge and resource expert for ECM, CS and/or SDOH provider network operations. * Establish and manage positive and productive working relationships with all public and community-based providers and vendors delivering services to members under ECM, CS or SDOH projects. * Receive, research and respond to inquiries and issues that are raised by or impacting providers in a timely fashion and in collaboration with appropriate business units. * Proactively communicate and collaborate with providers to identify problem patterns, track and trend issues, prepare recommendations for potential service improvement opportunities and develop tools and processes to improve communication and other processes * Oversee collaboration with internal business units, particularly Provider Network Operations, Health Services Department, Finance and Claims, regarding provider communication, training and support and to ensure payments are made in accordance with vendor agreement terms. * Schedule, conduct and report on regular site visits with each provider as required and coordinate and host at least one annual meeting with providers. * Conduct orientation and ongoing training and education to community service providers and office staff including technical assistance, development of presentations and other written guidance or materials, in-person sessions, webinars and/or calls as needed. * Assist in the preparation of promotional materials for the public, website or newsletters. Oversee provider compliance with required ECM and/or CS trainings and technical assistance including in-person sessions, webinars, and/or calls as necessary. * Establish and oversee a program for communicating and tracking ECM and/or CS provider compliance with vendor agreement scope of work, key operational and financial objectives, and quality and performance metrics. * Maintain accurate and timely documentation of provider contacts in compliance with NCQA standards, DHCS, DMHC and CMS regulatory requirements. * Contribute to the development of ECM and/or CS pricing including recommending changes in pricing subsystems. * Support the Department Manager in generating reports and performing special projects. Troubleshoot with providers to address issues related to submission of claims and encounter data for ECM and/or CS services. * Understand and track applicable regulatory and reporting requirements. * Ensure accuracy and regulatory compliance for all materials or documents. * Attend off-site meeting or events as necessary. * Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Bachelor's Degree in public health, social welfare or related field; or equivalent experience, training, or coursework. (R) * Minimum two years of progressively responsible and direct work experience working with the essential duties and responsibilities described above. (R) * Demonstrated experience leading/managing projects, initiatives, and/or leading or directing the work of others. (R) * Knowledgeable in the field of home and community-based services and community resource networks and a particular interest in working to address health disparities and addressing the needs of low-income communities. * A deep understanding of SDOH that impact Santa Clara County and community members. (R) * Ability to think creatively and work strategically, to help develop and implement innovative solutions yielding measurable results to the organization. (R) * Ability to think creatively and strategically, gather and analyze data, organize and write reports, organize work efficiently. (R) * Ability to understand, interpret, and apply applicable rules and regulations, and establish and evaluate priorities. (R) * Advanced working knowledge and proficient with Microsoft Suite applications, and the ability to operate all applicable software. (R) * Excellent oral and written communication skills, including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments and outside entities over the telephone, in person or in writing.(R) * Ability to effectively facilitate meetings and deliver information/presentations to management, regulators, or staff (R). * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to take initiative and exercise good judgment when making decisions within the scope of the position. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to perform the job safely with respect to others, to property, and to individual safety. (R) * Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) * Knowledge of the community-based delivery system and managed care. (D) * Project Management Professional (PMP) certification (D) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to regular contact with co-workers, managers, external partners, and vendors, in person, by telephone, and via work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person, by telephone, and electronically, throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.

FLSA Status: Non-Exempt Department: Claims Reports To: Supervisor or Manager of Claims Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521. The Claims Analyst II analyzes, processes and adjusts routine and complex facility and professional claims for payment or denial to support the Claims Department operations in a manner that maintains compliance within the Medicare and Medi-Cal regulatory requirements and achieves Claims service-level objectives. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. 1. Follow established Health Plan policies and procedures and use available resources such as provider contracts, Medicare and/or Medi-Cal guidelines and Member Evidence of Coverage (EOC) to analyze, process and adjust routine and complex assigned claims in an accurate and timely manner. 2. Research, identify, resolve and respond to inquiries from internal Health Plan departments regarding outstanding claims-related issues. 3. Assist Claims Supervisor and Manager with pre-check run reports. 4. Maintain and organize all processes related to Third Party Liability (TPL) claims, including communication of relevant information to appropriate parties. 5. Participate in system testing and communicate newly-identified and potential issues to the Claims Supervisor and Manager and provide recommendations for improvement. 6. Process claims refund checks on a weekly basis to ensure accuracy/completeness of information and submit to the Finance Department in a timely manner. 7. Attend and actively participate in daily, weekly, and monthly departmental meetings, training and coaching sessions. 8. Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. 1. High School Diploma or GED. (R) 2. Minimum two years of claims processing experience in a Health Plan Claims Department. (R) 3. Prior experience with managed care plans, Medi-Cal and/or Medicare programs, and working with underserved populations. (R) 4. Ability to analyze, process and adjust routine and complex assigned claims in an accurate and timely manner. (R) 5. Understanding of professional and hospital reimbursement methodologies, including medical terminology, and working knowledge of CPT, HCPCS, ICD-10, and ICD 9 codes. (R) 6. Understanding of the relationship between the health plans, IPAs, and DOFR. (R) 7. Ability to consistently meet Quality and Productivity Key Performance Indicators by participating in and achieving the Claims Quality standards. (R) 8. Ability to consistently meet Attendance Key Performance Indicator by being punctual and meeting the Claims standards in accordance with the team schedule. (R) 9. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel. (R) 10. Ability to use a keyboard with moderate speed and a high level of accuracy. (R) 11. Working knowledge of QNXT claims processing software. (D) 12. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R) 13. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) 14. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) 15. Ability to maintain confidentiality. (R) 16. Ability to comply with SCFHP's policies and procedures. (R) 17. Ability to perform the job safely with respect to others, to property, and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: 1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) 2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) 3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) 4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) 5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) 6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.

FLSA Status: Exempt Department: Case Management Reports To: Health Services Management The Social Work Case Manager is responsible for providing on-going case management services for Santa Clara Family Health Plan (SCFHP) members. As a SCFHP member advocate, the Social Work Case Manager II facilitates communication and coordination among all participants of the care team, to ensure member identified goals and needed services are provided to promote quality cost-effective outcomes. Through the development and implementation of member individualized care plans, the Social Work Case Manager II provides psychosocial and behavioral case management support to help coordinate resources and services for individuals across the healthcare and social services continuum, and facilitates the use of available healthcare benefits in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. * Conduct, review and document comprehensive psychosocial assessments for assets and deficits and on-going follow-up interventions to measure progress towards meeting goals as they relate to a member's physical, psychosocial, environmental, safety, developmental, cultural and linguistic needs. * Maintain case files by ensuring that they are documented timely in accordance with SCFHP policies and procedures, state and federal requirements and organized in a manner that adheres to standards for audit requirements. * Facilitate involvement of the member and/or family/responsible party for development and implementation of a member specific care plan which includes individualized prioritized goals. Provide appropriate social work interventions to members and/or family/responsible party with related psychosocial process teaching and information. * Coordinate member's care with primary care providers, specialists, behavioral health providers, Long Term Services and Supports providers, public services, community providers, and vendors as necessary and appropriate to assist member to achieve and maintain optimal level of functional independence to reside in the most appropriate level of care. * Communicate and coordinate member's psychosocial and behavioral health needs with member's interdisciplinary care team including SCFHP internal staff, as well as the member's providers, specialists, public services, community agencies and vendors to ensure appropriate care plan development and successful coordination of benefits and services aligned with the member's preferences. * Assist member's interdisciplinary care team in understanding social and emotional factors related to health condition and potential barriers and coping mechanism to accessing care. * Provides guidance, education and referrals to help members seek solutions to specific social, cultural, or financial problems that impact their ability to manage their health care needs. * Conduct telephonic and in-person interview, baseline assessments, survey, assess self-care ability, assess knowledge and adherence, comprehensive clinical assessments as indicated, and developing member centric plan in the office, home, facilities, clinics, or community settings. * Collaborate with team members on cross-departmental improvement efforts, organizational and departmental objectives, quality improvement projects, optimization of utilization management, and improvement of member satisfaction. * Attend and actively participate in Health Services meetings, operational meetings, training and coaching sessions, including off-site meetings as needed. * Perform other duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Master's Degree in Social Work, or related field. (R) * Certified Case Manager (CCM). (D) * Active California registered Licensed Clinical Social Worker (LCSW) without restriction. (R) * Minimum three years of experience in social work, behavioral health, or case management, or education or certifications, or equivalent experience. (R) * Knowledge of social case management and conflict resolution. (R) * Knowledge of long-term services and supports, behavioral health and/or relevant public services and community resources. (R) * Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R) * Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D) * Experience working with designated member population (e.g. behavioral health, seniors and persons with disabilities, children). (D) * Ability to work within an interdisciplinary team structure. (R) * Travel to off-site locations for work such as in office, home, facility, clinic, and other community settings. (R) * Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) * Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the operations as dictated by business needs. (R) * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R) * Ability to use a keyboard with moderate speed and a high level of accuracy. (R) * Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing as mandated by social work scope of practice. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to perform the job safely and with respect to others, to property and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.

FLSA Status: Exempt Department: Marketing & Communications Reports To: Manager, Marketing Production The Graphic Design Project Manager develops, manages, and implements SCFHP's brand in all print and digital communications and manages website development in support of departmental and organizational objectives and in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. * Manage graphic design from inception to fulfillment in support of marketing and communications objectives and regulatory requirements, working with both internal and external stakeholders, as required. * Develop new materials (hard copy or electronic) and update existing materials as needed to support programs, projects, and events. * Develop the organization's brand and maintain its integrity in all materials. * Develop and maintain effective systems to track all graphic design pieces, associated costs, and related expenses; analyze data to determine effectiveness and prepare marketing reports for management review. * Identify, evaluate, and manage vendors to achieve Departmental objectives. * Manage selection, ordering, design and proof approval of all marketing collateral, displays, and giveaway items. * Manage website development to maintain and improve user experience and accessibility, and maintain brand experience across all digital platforms, working with internal stakeholders and external vendors. * Develop, maintain, and use policies and procedures, operating instructions and tools needed to support marketing and communications activities. * Analyze and track compliance with applicable regulatory and reporting requirements; monitor new requirements and update required documents accordingly. * Attend and actively participate in department meetings, trainings, and coaching sessions. * Identify issues, trends, and opportunities to improve efficiency and/or quality, or to better assist departments; develop recommendations and implement same relative to identified issues, trends, and opportunities. * Attend offsite meetings or events as necessary. * Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Bachelor's Degree in Marketing, Communications or related field, or equivalent experience. (R) * Minimum three years of experience in graphic design and web development. (R) * Minimum one year of experience in project management. (R) * Ability to establish and maintain effective internal and external working relationships to organize and lead cross-functional teams. (R) * Strong computer skills including fluency in Microsoft Word, Excel, PowerPoint, Adobe Acrobat, and Adobe Creative Suite; experience writing and managing complex documents including use of styles, bookmarks, and other document setup/management tools; and use of the Web for research. (R) * Knowledge of Content Management System/HTML used for editing and maintaining website. (R) * Very strong oral and written communication skills, with the ability to communicate data and information professionally, effectively, persuasively and on a timely basis to diverse individuals and groups inside and outside of the organization. (R) * Ability to understand, interpret and communicate complex processes and abstract concepts for a variety of audiences. (R) * Ability to think creatively and work strategically. (R) * Ability to gather and analyze data, organize and write reports, and organize work efficiently. (R) * Ability to produce accurate and precise work, detect discrepancies and resolve discrepancies all while meeting deadlines. (R) * Ability to understand, interpret, and apply applicable rules, regulations, and establish and evaluate priorities. (R) * Self-directed with proven ability to assume responsibility, work independently, meet deadlines, prioritize, and move projects to completion with minimum supervision. (R) * Ability to take initiative and exercise good judgment when making decisions within the scope of the position. (R) * Ability to think and work effectively under pressure. (R) * Ability to maintain confidentiality. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to perform the job safely and with respect to others, to property, and to individual safety. (R) * Fluent in written Spanish, Vietnamese, and/or Chinese. (D) * Knowledge of healthcare, Medi-Cal managed care, and Medicare programs. (D) * Project Management Professional (PMP) certification. (D) PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 20 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.

The Manager of Quality Incentive Programs is responsible for managing Partnership HealthPlan's Primary Care, Hospital, and Long Term Care Quality Incentive Programs, also known as Quality Improvement Programs (QIPs). The QIPs provide financial incentives, data, and technical assistance to our provider network for meeting performance improvement targets. As part of this work, the position oversees Partnership's Provider Data Portal which allows providers to evaluate their performance and obtain data to manage their patients and ultimately improve care. Responsibilities Provides oversight, mentoring, and coaching to the QIP team in the following areas: Development and implementation of communication plans and presentations to Partnership's leadership and physician committees; Strategic leadership to all QIP programs including experience formulating objectives and priorities and implementing plans consistent with long term views/vision. Capitalizes on opportunities and effectively manages risks; Provides direction to the planning, implementation, and evaluation of all components for quality incentive programs; Provides advice and support on quality incentives programs run through other Partnership departments, such as, the pharmacy 340B QIP, the mental health QIP, and the specialty QAIP; In conjunction with the Partnership leadership team and community stakeholders, develops other pay for performance programs, as needed; Works collaboratively with IT and Health Analytics departments on the data systems to support regular measurement and feedback on the QIP measures; Researches and advises on program, payment, and incentive methodologies for quality incentive programs; Models data-driven leadership, ensuring interventions are measured and evaluated for efficacy and impact; Understands and exhibits expert knowledge in the various components of the QIPs. In conjunction with the Director of QI/PI and the CMO, oversees the development, implementation, and evaluation of the Provider Data Portal: Works with Partnership departments, business analysts, and providers to gather business requirements through observation, interviews, and facilitated questions; Works with business analysts, vendors, and IT department to develop prototypes for the portal; Oversees the testing, implementation, long-term management, and continuous improvement of the portal; Oversees the data integrity and reporting from the portal by ensuring data management and validation processes are in place; Provides direction to the team on all aspects of the portal. Leads a high performing team: Supports the development of the QIP and Provider Portal teams by establishing clear goals, expectations, and metrics to ensure that they are used to continually motivate staff and support meeting department goals and objectives; Hires, trains, coaches, supports, and directly supervises QIP staff. Regularly assesses staffing needs and advocates for additional staff as required. Serves as member of QI Department and Health Services Management Teams: Supports QI Department Director in budget management, staffing decisions, and strategic and operational planning; Collaborates with department director and QI management team to ensure alignment of efforts across the department. Helps develop and manage communication feedback loops so work from other areas (i.e. QIP programs, HEDIS, analytics, regional offices) informs QIP and Data Portal priorities, and vice versa; Collaborates extensively with QI staff in Redding office to foster alignment and cohesion across QIP, provider data portal, and other QI department functions; Attends Health Services Management Team meetings and stays informed of critical work across Health Services department. Advises of Health Services department strategy and continually assesses and adjusts operational plan of QIP team to support this larger strategy; Works with other directors and managers across the QI department and Partnership as a whole on data and measurement related activities, including the Quality Improvement Program, Partnership Stars Dashboard, provider reporting tools, and internal dashboards and program evaluations. Stays informed on key developments in the quality improvement field that impact our provider network, including patient-centered medical home certification criteria, meaningful use, primary care transformation best practices, and quality reporting requirements. Stays informed of key developments and research in the area of Pay for Performance. Assures that processes for Quality Improvement projects are HIPAA compliant and implements any needed changes or upgrades. Accepts other responsibilities as determined by the needs of the QI Department. Qualifications Education and Experience Bachelor's degree is required; Master's degree in healthcare is strongly preferred. At least four (4) years of experience in project management related to healthcare. Prior supervision of staff is required. Special Skills, Licenses and Certifications Advanced data analytic skills. Knowledge of healthcare quality data. Understanding of improvement measurement and analysis using run charts (trending data over time), and making decisions based on these data. Valid California driver's license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business. Performance Based Competencies Strong written and oral communication skills. Strong organization skills to work on multiple projects simultaneously within established time frames. Ability to plan, implement, and report on quality management projects. Strong analytic and critical thinking skills. Work Environment And Physical Demands More than 50% of work time is spent using a desktop computer. When necessary, the ability to lift, carry, or move manuals and reports, weighing up to 25 lbs. Must be able to work in a fast paced environment and maintain courtesy and composure when dealing with internal and external customers. Ability to function effectively with frequent interruptions and direction from multiple team members. All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan's policies and procedures, as they may from time to time be updated. HIRING RANGE: $118,518.94 - $154,074.63 IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

FLSA Status: Exempt Department: Health Services Reports To: Health Services Management The RN Case Manager is responsible for providing on-going case management services for Santa Clara Family Health Plan (SCFHP) members. As a SCFHP member advocate, the RN Case Manager facilitates communication and coordination among all participants of the care team to ensure member identified goals and needed services are provided to promote quality cost-effective outcomes. Through the development and implementation of member individualized care plans, the RN Case Manager provides medical and psychosocial case management support to help coordinate resources and services for individuals across the healthcare and social services continuum, and facilitate the use of available healthcare benefits in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. * Conduct, review and document comprehensive clinical and/or psychosocial assessments and on-going follow-up interventions to measure progress towards meeting goals as they relate to a member's physical, psychosocial, environmental, safety, developmental, cultural and linguistic needs. * Maintain case files by assuring that they are documented in accordance with SCFHP policies and procedures, state and federal requirements and organized in a manner that adheres to standards for audit requirements. * Facilitate involvement of the member and/or family/responsible party for development and implementation of a member specific care plan which includes individualized prioritized goals. * Coordinate member's care with PCP, Specialists, Behavioral Health and Long Term Services and Supports providers to assist member to achieve or maintain a level of functional independence which allows them to remain at home or in the community. * Facilitate and coordinate communication with member's interdisciplinary care team including SCFHP internal staff, as well as the member's physicians, specialists, public services, community agencies and vendors to ensure care plan development and coordination of benefits and services. * Facilitate successful transition of care for members who move between care settings by coordinating services for medical appointments, pharmacy assistance and by facilitating utilization review. * If assigned to MLTSS, support the transition of long-term care members residing in nursing facilities to a lower level of care, or community setting in partnership with MLTSS providers and programs. * If assigned to Community Based Adult Services (CBAS): * Conduct face-to-face, on-site eligibility determinations for CBAS services with members using the standardized California Department of Health Services approved tool - CBAS Eligibility Determination Tool (CEDT) & Patient Health Record Quick Guide; * Review and approve Individual Plan of Care for CBAS members; and * Provide care coordination to targeted CBAS members including assessment, care plan implementation and care transitions. * Conduct telephonic and/or visits/assessments, as needed in the home, facility or community setting. * Collaborate with team members on cross-departmental improvement efforts, quality improvement projects, optimization of utilization management, and improvement of member satisfaction. * Attend and actively participate in Health Services meetings, operational meetings, training and coaching sessions, including off-site meetings as needed. * Perform other duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Active California RN License without restriction. (R) * Minimum three years of experience in case management, discharge planning, or education or certifications, or equivalent experience. (R) * Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management. (R) * Clinical knowledge and critical thinking skills with the ability to assess individualized whole-person care needs necessary to develop an effective care plan. (R) * Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R) * Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D) * Experience working with designated member population (e.g. behavioral health, seniors and persons with disabilities, children). (D) * Ability to work within an interdisciplinary team structure. (R) * Ability to conduct home, facility and other community-based visits. (R) * Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) * Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the operations as dictated by business needs. (R) * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R ) * Ability to use a keyboard with moderate speed and a high level of accuracy. (R) * Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing as mandated by nursing scope of practice. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to perform the job safely and with respect to others, to property and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.

FLSA Status: Exempt Department: Information Systems Reports to: Manager, IT Configuration Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 The Configuration Data Analyst is responsible for system configuration, implementations and conversions of SCFHP's core systems. This position is responsible for the accurate interpretation and associated configuration of regulatory federal and state guidelines. along with business contractual agreements impacting benefits, contracts, millions of dollars in claims payment, case management, and/or grievance and appeals within core systems. The Configuration Data Analyst must have the ability to meet with internal and external business units and peers to gather requirements, independently analyze and mine data, draw sound conclusions, configure, test and implement the data structures that support SCFHP's managed care information system (s) required to meet business needs, regulatory compliance, and vendor contractual obligations. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. * Comprehensive understanding of capitation models in order to setup within our core system to support multiple delegate contracts averaging approximately 50 million dollars in monthly capitation payments, based on accurate setup and configuration. * Comprehensive understanding and ability to interpret simple and complex provider contracts and amendments in order to setup within our core system reimbursement for, but not limited to, hospitals, provider groups, ancillary providers averaging approximately 1 million dollars in weekly claim payments, based on accurate setup and configuration. * Comprehensive understanding and ability to interpret federal and state government (DHCS and CMS) guidelines, and eligibility and enrollment process in order to setup core systems for claims, case management, and grievance and appeals * Combine in-depth analysis of business unit requirements and comprehensive understand of core system capabilities, knowledge of claim processing, provider and vendor setup, authorizations and business processes in order to determine optimal core system setup to process claims, case management, and grievance and appeals with a high degree of accuracy and auto-adjudication. * Serve as a subject matter expert for multiple core systems including but not limited to QNXT, Essette, Beacon, Zipari, NetworX, Optum CES (Claims Editing System), etc. * Troubleshoot small to large scale, basic to highly complex business and system production issues by thoroughly reviewing the issue, researching within internal and external documentation such as regulatory publications, and system user guides, performing analysis and critical thinking and testing in order to identify a root cause, document findings, and recommend solutions * Perform basic to highly complex system configuration and maintenance of system rules including but not limited to benefits, authorizations, contracts, fee schedules, DFRs, capitation, letter templates, etc. in order to fix production support issues, or support business needs and regulatory requirements in multiple system applications (such as QNXT, Essette, CES, etc.) for multiple lines of business. * Coordinate the loading, validation, and testing of third party software updates, rate changes, and code changes (CPT, Diagnosis, etc.) with business units and outside vendors, as needed. * Combine in-depth analysis of application configuration and data, information gathered through independent research, knowledge of system capabilities and interdependencies, and business processes to determine the best configuration in order to ensure overall accuracy and efficiency of system processing * Project and task management for small to large scale configuration projects including but not limited to: Attend meetings with business units to gather requirements, track actionable items, send regular communications, escalate identified risks, recommend, implement, and test configuration changes. * Develop documentation of changes, system issues, defects, and bugs including formal requirements, functional specifications, step-by-step configuration setup, root cause, test results reflecting impact to affected business units, manager, and/or external third party vendors. * Perform unit testing and post audit to ensure quality, accuracy, and completeness of work. * Conduct post implementation internal review and analysis in order to refine system rules to further optimize configuration for greater efficiency and accuracy. * Assist in all aspects of new system and new line of business implementations and conversions, as well as core system updates. * Create and maintain basic to moderate SQL based to support business and system processes and initiatives. * Provide training and cross-training to business units on system features and/or new releases. * Mentor and provide training to other configuration analysts or business system analysts on configuration, system features, and/or new releases * Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Bachelor's Degree in Healthcare, Information Systems, or related field, or equivalent experience, training or coursework. (D) * Experience in healthcare (D) * Minimum three years of experience performing the above responsibilities or a minimum of 5 years Claims processing or application vendor experience in a managed care environment. Other additional qualifications may be used to substitute for a required experience. (D) * Ability to work in a group environment and clearly communicate discussion points as needed. (R) * Ability to understand technical requirements and configuration logic to ensure systems are properly configured to meet business needs. (R) * Ability to meet deadlines, multi-task, troubleshoot, and problem-solve. (R) * Must be able to utilize analytical skills to conceptualize and envision impact of changes, and recommend resolutions for business or system issues and gaps. (R) * Ability to audit implemented changes to detect and resolve discrepancies to ensure work is accurate and precise. (R) * General understanding of health care data sets such ICD9/10, CPT/HCPCs, provider contracts and benefits, authorizations, etc. (R) * Knowledge of relational databases such as SQL and Microsoft Access. (D) * Knowledge of CMS and DHCS pricing and benefit structure (D) * Claims processing and Claims Management System configuration experience. (D) * Ability to read and interpret technical procedures, government regulations and guidelines, and various contract provisions, and apply the knowledge. (R) * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel. (R) * Ability to use a keyboard with moderate speed and a high level of accuracy. (R) * Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R) * Ability to perform the job safely with respect to others, to property, and to individual safety. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with SCFHP's policies and procedures. (R) * Knowledge of project management principles. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.

Under the general direction of the CIO, the Director, IT Strategic Initiatives is responsible for overseeing IT strategic initiatives; developing, implementing, and auditing methodologies and best practices related to steering committees; and prioritization of projects and best practices related to the Systems Development Life Cycle (SDLC). The Director will be responsible for ensuring that there is a consistent development and implementation process and that it is followed. The Director will work with the CIO and other department directors to prioritize projects and provide status reports to the CIO and Steering Committee. Responsibilities Manage and lead the IT Strategic Initiatives team made up of Project Managers, IT Business Analysts, and Quality Assurance. Manage and maintain a process to review, prioritize, and monitor incoming work requests. Identify metrics and provide status reports around projects. Tailor SDLC process to meet PHC needs and ensure it is followed. Assign Project Managers, IT Business Analysts, and Quality Assurance resources based on importance and complexity of projects. Audit documentation from IT projects to ensure it is completed correctly. Assist in project portfolio management and the Statement of Work process. Measure and report on project progress, including metrics around meeting schedules, error rates, etc. Work with other IT Directors to support all IT projects. Work with PHC's PMO department to ensure processes, methodologies, and priorities are aligned. Develop a standard testing and QA methodology and ensure testing and QA is in each project plan. SECONDARY DUTIES AND RESPONSIBILITIES Assist in special projects where needed. May serve as a project manager or business analyst on special projects. Provide expert guidance to the user community. Qualifications Education and Experience Bachelor's degree in Computer Science or related field preferred. At least four (4) years as an IT Project Manager, Business Analyst, or related experience. Minimum two (2) years working in a management role. Experience developing IT processes and procedures. Special Skills, Licenses and Certifications Knowledge of programming practices, systems analysis, and system selection. Ability to translate user requirements into system specifications. Project Management certification desirable. Valid California driver's license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business. Performance Based Competencies Excellent communication skills with the ability to present to large audiences. Strong knowledge of Microsoft Office products including Microsoft Project and PowerPoint. Ability to develop presentations. Work Environment And Physical Demands More than 50% of work time is spent in front of a computer monitor. May be required to bend, stoop, kneel, crawl, or work in other non-standing and non-sitting positions to install cabling, systems hardware, and other related equipment. All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan's policies and procedures, as they may from time to time be updated. HIRING RANGE: $ 180,252.50 - $ 243,340.87 IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

Provide a range of social work services in collaboration with Partnership 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. Responsibilities Travels to meet members, families and/or caregivers in the community to address case management and care coordination needs. Develops an individualized care plan addressing the psycho-social elements and non-medical barriers to health in an effort to promote and ensure optimal care coordination of the member's needs. Conducts interview assessments with individuals, families and/or caregivers to identify a member's needs, goals and/or barriers. Sets priorities according to treatment goals and member's preferences in a timely manner. Supports successful transitions and coordination of services across the care continuum (ex: pediatric to adult settings, acute/post-acute to community, adaptation to disability or trauma, etc.) via effective and frequent communication and collaboration with providers, the member, family and/or caregiver. Arranges, coordinates and monitors the use of community services/resources available to members, family and/or caregivers. (ex: housing options, financial assistance, special education options, vocational training/employment, legal aid services, etc.) Assists members in selecting appropriate resources and/or contacting resources on behalf of the member. Provides support in obtaining necessary forms, filling out documents/applications when appropriate. Provides education and support to members, families, caregivers and/or Partnership staff regarding conservatorship, Public Guardianship, Power of Attorney and/or Authorized Representative options for members with identified needs. Uses Motivational Interviewing strategies and clear communication/limit setting to promote member's self-management, reduce risk of system(s) dependency, and improve health and well-being. Documents interventions and activities according to departmental policies and procedures. Collaborates with colleagues to provide education and support to members with identified psycho-social and/or resource needs. Participates as part of a multidisciplinary team in Partnership's integrated rounds; presenting complex member cases when needed and offering suggestions or support to others. Maintains working knowledge of public/private community resources and fosters collaborative working relationships on behalf of Partnership. Actively participates in outreach meetings or case conferences in the community, including hospitals, skilled nursing facilities, community-based organizations, etc. Engages in essential skills training as directed or assigned. Other duties as assigned. Qualifications Education and Experience Bachelors or Masters degree in Social Work, Minimum of two (2) years of social work in a healthcare or public health setting preferred or equivalent work experience considered. Special Skills, Licenses and Certifications Valid CA driver's license and proof of current Automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business. Performance Based Competencies Experience with human growth and development, group and family dynamics, principles of individual and group behavior, provisions of federal, state, and local welfare programs and the laws, rules, and regulations governing their applications: community organizations and resources: socioeconomic conditions and trends: current problems and methodology in public social service. Ability to: assess and evaluate data and develop an effective course of action; make effective use of resources and services in the community; develop and maintain effective working relationships with members, departmental staff, public and private Social Service agencies, community based organizations, and the public; control personal bias and apply social work ethics; input data, reports and narratives into a computer system; keep detailed records and prepare reports and correspondence. Bilingual skills in Spanish preferred. Work Environment And Physical Demands Daily use of telephone, fax, computer, and photocopying machine is required. Standard cubicle workstation with a shared common area. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs. Frequent travel and/or field-based work (at least 50% driving travel required). All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan's policies and procedures, as they may from time to time be updated. HIRING RANGE: $45.04 - $56.30 IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

To plan, organize, manage, and implement projects. Responsibilities Develops and maintains detailed project plans and budget summaries. Coordinates and facilitates both internal and external meetings. Supports projects with a range of low to medium complexity, scope, and schedule. Supports the successful implementation of projects within timelines for associated department assignments and tasks. Provides technical and administrative support for the development of business cases and system reports for projects and/or programs. Develops and publishes agendas, meeting minutes, and necessary documentation. Works with department to develop tactical department and program initiatives. Works with relevant units to develop effective and high quality projects to meet the needs of associated PHC departments. Identifies and manages project deliverables, dependencies, and critical path milestones. Attends project meetings, follows up on assigned tasks, and communicates the status of projects to the supervisor. Develops and publishes communications to project stakeholders. Manages, tracks, and processes project paperwork. Maintains department files (hard and soft copies) per instruction. Other duties as assigned. Qualifications Education and Experience High School diploma or equivalent. Minimum of one (1) year project coordination experience. Special Skills, Licenses and Certifications Strong organization skills with ability to prioritize assignments, manage time effectively, and coordinate project activities between multiple groups. Effective communication skills, both verbal and written, to interpret and articulate project requirements to involved stakeholders. Ability to interpret project requirements and project budget. Valid California driver's license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business. Performance Based Competencies Must be able to work in a fast-paced environment and maintain courtesy and composure when dealing with internal and external customers. Ability to function effectively with frequent interruptions and direction from multiple team members. Maintains confidentiality and integrity at all times. Work Environment And Physical Demands More than 50% of work time is spent using a desktop computer. When necessary, the ability to lift, carry, or move objects of varying size, weighing up to 10 lbs. All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan's policies and procedures, as they may from time to time be updated. HIRING RANGE: $34.79 - $43.48 IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

FLSA Status: Exempt Department: Information Technology Reports To: Director, Infrastructure and Systems Support Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 The Systems Database Administrator is responsible for database security, integrity, performance, availability, and recoverability of databases, database servers, and related systems. In addition, the Systems Database Administrator is responsible for installing, configuring, and maintaining database servers, databases, related objects, and related software and for database security in support of SCFHP objectives and regulatory compliance. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. * Provide technical management and support for the organization's database environments to ensure database security, integrity, performance, availability and recoverability of databases, database servers, and related systems. * Develop, implement, and periodically test backup and recovery plan for the production of critical databases to ensure the business continuity plan is accurate and effective. * Ensure database security by controlling access to databases through authentication and authorization and performing auditing of database usage and active users. * Audit database security and user access to ensure HIPPA regulatory law reporting requirements are met. * Monitor database server resources to ensure production environments meet performance and availability requirements. * Install, test, secure and maintain new versions of database software, patches and other associated software application changes or upgrades. * Provide storage and capacity planning, long and short term, to ensure adequate space is available for all database environments. * Document database architecture, including developing and maintaining database installation and configuration procedures, data governance program, change control deployment procedures, and SQL coding guidelines. * Work with the application development team to ensure that appropriate and efficient SQL is coded and tested prior to production deployment. * Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Bachelor's Degree in Computer Science, or related field, or equivalent experience, training or coursework. (R) * Minimum three years of experience serving as a systems database administrator in a Microsoft SQL Server environment with versions currently supported by Microsoft. (R) * Microsoft Certified Solutions Expert (MCSE). (D) * Minimum three years of experience maintaining multiple database environments and regions to support production, development and test areas of business systems; including managing database security, database tuning, query optimization, and application code deployment. (R) * Minimum three years of experience SQL Scripting and Command Shell scripting. (R) * Minimum three years of experience with any of the following applicable languages/platforms: .NET, PERL, Java, SAS, VB, C++, or other modern programming language or related software. (R) * Minimum three years of experience with MS SQL Business Intelligence tools (SSRS, SSIS, SSAS) or other enterprise business intelligence software. (R) * Experience maintaining a data warehouse database environment, including managing and enforcing data governance and coding best practice. (R) * Ability to create and maintain documentation of source code, application installation processes, technical specifications, and data governance program. (R) * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel. (R) * Ability to use a keyboard with moderate speed and a high level of accuracy. (R) * Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with SCFHP's policies and procedures. (R) * Ability to perform the job safely with respect to others, to property, and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.

FLSA Status: Non-Exempt Department: Health Services Reports To: Supervisor, Utilization Management The Medical Management Care Coordinator I performs non-clinical supportive duties related to utilization management (UM) and care coordination for Santa Clara Family Health Plan (SCFHP) members. Routine supportive duties include but are not limited to data entry into system software applications, managing department telephone queues, and assisting with quality monitoring projects for both SCFHP lines of business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, Care Coordinator Guidelines and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. * Follow established Health Services policies and procedures and use available resources to respond to member and/or provider inquiries and resolve any concerns in an accurate, timely, respectful, professional and culturally competent manner * Collaborate with team members on improvement efforts across-departments regarding quality improvement projects, optimization of utilization management, and member satisfaction. * Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing. * Assist in gathering and processing data for internal required reports and analysis. * Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions. * Follow UM policies and processes to the management of incoming authorization requests received through fax, mail or telephone. * Identify authorization requests for line-of-business, urgency level, type of service, and assess for complete/incomplete record submission. * Perform complete, accurate, and consistent data entry into system software applications in accordance with policies, procedures and instruction from UM management. * Answer inbound UM phone queue calls timely to assist members and/or providers regarding inquiries involving authorizations, SCFHP program services, and/or benefits. * Process written and verbal notifications of authorization determinations to members and/or providers within regulatory processing timeframes. * Perform other duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * High school diploma or GED. (R) * Minimum two years of experience in a health care setting in positions requiring interaction with members and/or providers. (R) * Knowledge of health plan benefits, process and operations related to commercial, Medi-Cal and/or Medicare programs. (D) * Proficient in adapting to changing situations and efficiently alternating focus between telephone and non-telephone tasks to support department operations as dictated by business needs. (R) * Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R) * Demonstrated ability to consistently meet Key Performance Indicators by participating in and achieving the standards put forth to achieve the standard requirements of the Utilization Management Department (R) * Ability to work within an interdisciplinary team structure. (R) * Work weekends and company holidays as needed based on business and regulatory requirements. (R) * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific UM programs. (R) * Ability to use a keyboard with moderate speed and a high level of accuracy. (R) * Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to perform the job safely and with respect to others, to property and to individual safety. (R) WORKING CONDITIONS Duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.

FLSA Status: Non-Exempt Department: Health Services Reports To: Health Services Management Under the guidance and direction of the UM department RN Manager or Director, the Utilization Management Review Nurse (LVN) performs prospective and retrospective clinical review for inpatient and outpatient authorization requests in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and applicable business requirements. Following regulatory or evidence-based guidelines, assesses for medical necessity of services and/or benefit coverage which result in approved determination for services or the need to collaborate with Medical Directors for potential denial considerations. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. * Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective/claims review organization determination authorization requests within regulatory turnaround requirements for all SCFHP lines of business. * Process authorization reviews by applying the appropriate clinical criteria/guidelines, policies and procedures. * Draft and process timely notification of action (NOA) letters for authorization determinations to providers and to members, in member specific language preferences as identified within member demographic information. * Coordinate referrals to appropriate departments or programs for member identified continuity of care needs, such as Case Management, Behavioral Health, Managed Long Term Services and Supports (MLTSS), community resources, Pharmacy and Quality. * Maintain adherence with CMS (Medicare) and DHCS (Medi-Cal) regulatory requirements. * Facilitate appropriate processing of Letters of Agreement with non-contracted Providers for approved medically necessary services. * Perform other duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Active California Board of Nursing Licensed Vocational Nurse License (LVN) without restriction. (R) * Minimum one year of licensed related health care experience. (R) * One year of experience within a Managed Care Health Plan. (D) * Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management. (R) * Knowledge of MediCal and/or Medicare guidelines and regulations. (D) * Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards. (D) * Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R) * Ability to pass random quarterly case file reviews in accordance with departmental monitoring standards. * Ability to successfully pass departmental bi-annual inter-rater reliability testing. (R) * Ability to work within an interdisciplinary team structure. (R) * Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the operations as dictated by business needs. (R) Working knowledge of and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word, Excel, and specific case management programs. (R) * Ability to use a keyboard with moderate speed and accuracy. (R) * Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing as mandated by nursing scope of practice. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to perform the job safely and with respect to others, to property and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.

To accurately perform concurrent, retrospective, and special audits on all level I claim types for all Partnership lines of business. Responsibilities Perform concurrent and retro claims audits on new Claims examining staff and on claims processed by existing Claims staff as outlined in Claims Operating Instruction Memorandums for all lines of business. Document audits and report all audit outcomes following the Partnership Claims Operating Instruction Memorandums on claims auditing. Maintain current knowledge of Partnership Claims Policy and Procedures for all lines of business, Medi-Cal Provider Manual, Title 22 regulations, Knox Keene regulations, and CMS Medicare regulations. Perform special claims audits as assigned. SECONDARY DUTIES AND RESPONSIBILITIES Participate in special projects and assignments as required. Other duties as assigned. Qualifications Education and Experience Minimum two (2) years of claims examining experience and completion of Partnership Claims training; or equivalent combination of education the experience. Special Skills, Licenses and Certifications Familiar with Medi0Cal and/or managed care claims processing. Knowledge of CPT, HCPC procedure coding, and ICD -9/ICD10 diagnostic coding. Typing speed 30 wpm and proficient use of 10-key calculator. Familiar with AMISYS or similar claims systems. Understanding of claims examining requirements. Valid California driver's license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business. Performance Based Competencies Excellent oral and written communication skills. Ability to effectively exercise good judgment within scope of authority and handle sensitive issues with tact and diplomacy. Ability to work on multiple tasks within established time frames and sometimes conflicting priorities. Good organizational skills with ability to maintain accurate records and documentation of actions and decisions. Work Environment And Physical Demands Ability to use a computer keyboard. More than 60% of work time is spent in front of a computer monitor. When required, ability to move, carry or list objects of varying size, weighing up to 5 lbs. All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan's policies and procedures, as they may from time to time be updated. HIRING RANGE: $ 30.38 - $ 36.46 IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

FLSA Status: Non-Exempt Department: Grievance and Appeals Reports To: Supervisor, Grievance and Appeals Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 The Grievance and Appeals Coordinator is responsible for the beginning-to-end process of receiving, researching and resolving of new and existing member and provider grievance and appeals cases for all lines-of-business including any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and SCFHP policies and procedures as set forth for each line of business. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. * Act as a back-up to the Grievance and Appeals Intake Specialist during times of high volume work and/or staffing shortages to ensure appropriate intake of new and existing grievance and appeal cases, assessing the priority of each case and routing to the appropriate staff. * Ensure grievance and appeals cases are accurate and include the necessary elements for processing and resolving, giving special attention to those identified as "Expedite". Create clear and concise documentation in applicable system(s). * Use good judgment and department resources to identify all issues and required actions within a case, appropriately categorize cases and identify required actions in accordance with state and federal regulations. * Produce and manage outbound documents, correspondence and reports in a manner that meets required timeframes. * Ensure adherence with state and federal regulatory timeframes for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters and communicating with members and providers within required timeframes. * Prepare case files for State Fair Hearings, Independent Review Entities or other escalated types of cases, including documentation of the Statement of Position and case narratives. Represent SCFHP in any hearing proceedings. * Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing. * Contact members and providers to seek additional information or clarification regarding grievance and appeals cases and review and resolve issues by requesting medical records, notice of action, or any other pertinent information related to grievances and appeals from medical groups, delegated entities and/or providers. * Perform complete, accurate and consistent data entry into system software applications in accordance with policies, procedures and instruction from the Manager of Grievance and Appeals Operations. * Maintain case files by ensuring that they are documented in accordance with state and federal requirements and organized in a manner that adheres to SCFHP standards and audit requirements. * Participate in retrospective audit and review of cases and complete and correct gaps or errors in data. * Identify operational issues and trends with SCFHP, delegates and other external stakeholders. Communicate these issues internally and externally and assist in formulating appropriate remediation plans. * Assist the Manager of Grievance and Appeals Operations and peers with special projects. Work collaboratively and cross-functionally with other departments to facilitate appropriate resolutions. Work as a team to complete departmental tasks to meet deadlines and accomplish department objectives. * Attend and actively participate in Grievance and Appeals Committee meetings, operational meetings and department meetings, trainings and coaching sessions. * Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * High School diploma or GED. (R) * Associate's degree or equivalent experience, training or coursework. (D) * Minimum two years of experience in customer service, provider service, health service, or pharmacy in a managed care or health care environment handling escalated or complex issues. (R) * Knowledge of health plan benefits, processes and operations. (R) * Prior experience with commercial, Medi-Cal and/or Medicare programs and working with the underserved populations. (R) * Work weekends and company holidays as needed based on business regulatory requirements. (R) * Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D) * Detail-oriented with the ability to conduct research and identify steps required to resolve issues and follow through to effectuation.(R) * Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the Grievance and Appeals Department operations as dictated by business needs (R) * Ability to consistently meet grievance and appeals accuracy and timeline requirements by achieving regulatory standards. (R) * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel. (R) * Ability to use keyboard with moderate speed and a high level of accuracy. (R) * Excellent communications skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, Members, Providers and outside entities over the telephone, in person or in writing. The ability to remain calm and de-escalate tense situations. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to perform the job safely with respect to others, to property and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment; (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office and call center conditions. May be exposed to moderate noise levels.

FLSA Status: Exempt Department: Health Services Reports To: Manager, Utilization Management The Supervisor of Utilization Management (UM) is responsible for the direct oversight of daily operations of utilization management activities, providing assistance with the development and implement of new programs and related workflows, policies, procedures for all lines of business, and serving as a resource for internal departments, members, providers, delegates, and community partners. In addition, the Supervisor of UM is responsible for supervising nurses and coordinators to ensure that all administrative UM processes are performed in accordance with all applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. 1. Collaborate with the Manager of Utilization Management to implement and supervise all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements including key performance indicators of MCAS, HEDIS, and CMS Stars for all lines of business. 2. Monitor and provide continuous analysis and quality monitoring of all policies and procedures to evaluate UM staff and delegate performance and ensure regulatory compliance, including the development and implementation of effective, measurable corrective action plans to meet targeted strategic outcomes. 3. Ensure the integration of UM operations such as prior authorization, concurrent review, Transitional Care Services (TCS), and discharge planning into other internal and external teams/departments including Quality & Process Improvement, Case Management, Community Based Programs, Pharmacy, and Behavioral Health. 4. Perform oversight and assignment of caseload across various utilization management functions including routine and ad hoc audits and monitoring of corrective action plans. 5. Establish and maintain effective interpersonal relationships with all SCFHP staff, members and/or their authorized representatives, providers and other program or agency representatives. 6. Resolve or facilitate resolution of problematic and/or complex issues by escalating to appropriate management/leadership person. 7. Ensure Utilization Management Committee preparedness. 8. Attend off-site meetings, events, or facility census review as necessary. 9. Perform other related duties as required or assigned. SUPERVISORY/MANAGEMENT RESPONSBILITIES Carries out supervisory/management responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include: 1. Recruiting, interviewing, and hiring. 2. Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives. 3. Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance. 4. Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work. 5. Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Unrestricted professional RN licensure in the state of California. (R) * Minimum two years of progressively responsible experience in a supervisory or lead capacity in case management, utilization management, discharge planning and/or quality improvement in a managed care related setting. (R) * Understanding and/or experience with Utilization Management. (R) * Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA Population Health Management standards. (R) * Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements. * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R) * Ability to use a keyboard with moderate speed and high level of accuracy. (R) * Excellent written, verbal, and interpersonal communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to think and work under pressure and effectively prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise sound judgment when making decisions within the scope of this position including performing job safely and within respect to others, to property and to individual safety (R) * Maintenance of a valid California Driver's License and acceptable driving record in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.

FLSA Status: Exempt Department: Health Services Reports To: Director of Medical Management The Manager of Utilization Management (UM) is responsible for the direct oversight of internal and external delegated UM functions including the development and implementation of policies, procedures and program development and related quality monitoring. In addition, the Manager of UM is responsible for supervising the Supervisor of UM to ensure that all administrative UM processes are performed in accordance with all applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. * Develop, implement and manage all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements for all lines of business. * Develop and implement continuous analysis and quality monitoring of all policies and procedures to evaluate UM staff performance and ensure regulatory compliance, including the development and implementation of effective, measurable corrective action plans to meet targeted strategic outcomes. * Ensure the integration of UM operations into other internal and external teams/departments including Quality, Long Term Services and Support (LTSS) and Behavioral Health (BH). * Establish and maintain effective interpersonal relationships with all SCFHP staff, members and/or their authorized representatives, providers and other program or agency representatives. * Ensure UM Committee preparedness. * Attend off-site meetings. * Perform other related duties as required or assigned. SUPERVISORY/MANAGEMENT RESPONSIBILITIES Carries out supervisory/management responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include: * Recruiting, interviewing, and hiring. * Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives. * Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance. * Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work. * Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Unrestricted professional RN licensure in the state of California. (R) * Minimum two years of experience in a supervisory capacity in a managed care setting. (R) * Understanding and/or experience with Utilization Management. (R) * Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA regulatory Population Health standards. (R) * Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements. * Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R) * Ability to use a keyboard with moderate speed and high level of accuracy. (R) * Excellent written, verbal, and interpersonal communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R) * Ability to comply with all SCFHP policies and procedures. (R) * Ability to think and work under pressure and effectively prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise sound judgment when making decisions within the scope of this position. (R) * Maintenance of a valid California Driver's License and acceptable driving record in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels. Frequent computer screen exposure.

FLSA Status: Exempt Department: Information Technology Reports To: Director, Application and Product Development The Manager of Application Development is responsible for the supervision of the application development staff in the design, development, implementation and support of in-house and vendor applications and interfaces, including the accurate data exchange between trading partners in accordance with state and federal regulatory and contractual requirements and SCFHP policies and procedures as set forth for all lines of business. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. * Supervise and mentor personnel performing design, development, implementation, maintenance, and reporting from application databases, data warehouse and data cube environments. * Oversee the design, development, implementation, and maintenance of electronic data exchange in multiple formats, including EDI X 12 transaction sets specific to healthcare transactions. * Oversee the development and maintenance of enterprise data warehouse. * Exercise staff oversight to ensure new operations plans, policies, procedures and transition/migration plans are consistent with the overall company goals and objectives. * Define and modify IT development standards, policies and procedures to ensure they remain current with business and regulatory needs. * Participate in the project approval and prioritization process with other IT management and business leaders. * Contribute and participate in the strategic planning process and share in the development of SCFHP vision, goals and initiatives. * Develop positive relationships with managers, directors and leaders by understanding business priorities and information technology enablers. * Perform other related duties as required or assigned. SUPERVISORY/MANAGEMENT RESPONSBILITIES Carries out supervisory/management responsibilities in accordance with SCFHP's policies, procedures, applicable regulations and laws. Responsibilities include: * Recruiting, interviewing, and hiring. * Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives. * Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance. * Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work. * Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Bachelor's Degree in Business Administration, Computer Science, Public Health, or related field, or equivalent training/experience. (R) * Minimum five years of experience in a lead or supervisory capacity. (R) * Minimum ten years of experience in application development. (R) * Minimum ten years of experience, with SQL programming, MS SQL database development, and T-SQL query generation. (R) * Minimum five years of experience with MS SQL Business Intelligence tools (SSRS, SSIS, SSAS) or other enterprise business intelligence software. (R) * Minimum five years of programming background in any of the following applicable languages/platforms; .NET, PERL, Java, SAS, VB, C++, C#, or other modern programming language or related software. (R) * Demonstrated knowledge of software development life cycle (SDLC), coding standardization, peer review and user acceptance testing. (R) * The ability to effectively manage multiple projects across multiple team members, including direct reports and other IT staff members. (R) * Excellent data analysis skills. (R) * Knowledge of and experience with healthcare management information systems. (R) * Good working knowledge of BizTalk, Sharepoint, ActiveBatch and other core integration tools and services. (D) * Working knowledge of and the ability to efficiently operate all applicable computer software including a working knowledge of computer applications such as Outlook, Word and Excel. (R) * Ability to use a keyboard with moderate speed and a high level of accuracy. (R) * Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) * Ability to maintain confidentiality. (R) * Ability to comply with SCFHP's policies and procedures. (R) * Ability to perform the job safely with respect to others, to property, and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to regular contact with co-workers, managers, external partners, and vendors in person, by telephone and via work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.