Alameda Alliance for Health jobs in Alameda, CA

Hybrid: Full Time must live in one of 6 states: CA, AZ, NV, TX, WA, OR; remote and on site in Alameda County. Available for Full-Time Work Schedule 8:00am - 5pm Pacific Time, Monday-Friday. Hybrid positions work a minimum of up to_2_ days per week in Alameda Alliance for Health's office, located at _Alameda CA, and a minimum of three days per week remotely. PRINCIPAL RESPONSIBILITIES: Member Services Representatives (MSR) are the first point of contact for our members' primary contact with the Alliance for both routine and complex member issues with the goal of delivering excellent customer service to our customers. The position is responsible for answering a high volume of inbound and outbound calls in a timely manner. Respond to all communications coming into Member Services in the form of email, fax, letters, chat and phone calls. Timely responses to all member communication are essential. Must effectively prioritize and flex the workload as new communication and tasks are submitted. Identify the caller's needs, clarify information, research issues, and provide solutions and/or alternatives whenever possible. Accurately and consistently document all conversations in the electronic database. This position is a liaison between the plan, the provider network, and other community agencies. The MSR positions are flexibly staffed classification and work is expected to be performed minimally at the MRS II level. However, the initial selection will be made at the entry level MSR I. Our more advanced level position of the series is the MSR III who will be required to perform a variety of complex matters. Member Services Representatives are under the direction of a Member Services Supervisor, Manager and Director, and service our members through our call center as well assisting other departments with responses to member issues by initiating communication between departments to ensure action, cooperation, and compliance of managed care operations. Member Services Representative I This position which requires the ability to work as a team player within the Alliance and with external contacts, make sound judgments based on analysis of information, be an effective communicator, active listener and balance advocacy for the member with the policy provisions such as plan policies, EOC, regulatory guidelines, and DMHC/DHCS rules and regulations. The MSR provides courteous, professional, and accurate responses to incoming inquiries regarding network, plan benefits, eligibility, authorizations, plan services and guidelines, as well make decisions with the goal of ensuring member satisfaction and retention. The MSR performs a variety of complex functions and is also responsible for maintaining accurate and complete inquiry/grievance records in the electronic database. Maintains compliance with DMHC regulatory requirements and DHCS contractual obligations. MSR I staff who demonstrate proficiency in meeting, maintaining and exceeding principal performance objectives and metrics may be eligible to be promoted to a Member Services II or III role. Member Services Representative I staff may be eligible for promotion to Member Services Representative II or III positions once they have worked as a MSR I for a minimum of 12 months to be proficient with program and system knowledge in addition to meeting performance matrix requirements. Principle duties and responsibilities * Serve as the primary contact for members, providers and others for questions related to claims, benefits, authorizations, pharmacy, member eligibility and other questions related to Alameda Alliance and provide accurate, satisfactory answers to their inquiries or concerns. * Respond to and resolve member service inquiries and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility, claims, behavioral health, and care coordination. * Answer incoming calls, emails, chats, and other requests for assistance in a timely manner in accordance with departmental performance targets and provide excellent customer service while doing so. May include assisting members in person. * Recognize and understand the difference between calls that require quick resolutions and calls which will require follow-up and handle each appropriately. * De-escalate situations involving dissatisfied customers, offering patient assistance and support. * Accurately document all contacts per department standards/guidelines in the Customer Relationship Management (CRM) system. * Accurately and consistently document (electronic database) and resolve Exempt Grievances (any expression of dissatisfaction that are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment and that are resolved by the next business day following receipt). * Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations, and other internal departments to provide Service Excellence to our members. * Help guide and educate members about the fundamentals and benefits of managed health care topics, to include managing their health and well-being by selecting the best benefit plan service options, maximizing the value of their health plan benefits, and choosing a quality care provider. * Intercede with care providers (doctor's offices) on behalf of the member, assisting with appointment scheduling; connect members with internal Case Management Department for assistance as needed. * Assist members in navigating alamedaalliance.org, the Member Portal, and other health care partner online resources and websites to encourage/reassure them to use self- service tools that are available. * Manage any issues through to resolution on behalf of the member, either on a single call or through comprehensive and timely follow-up. * Research complex issues across multiple databases and work with support resources to resolve member issues and/or partner with others to resolve escalated issues. * Provide education and status on previously submitted pre-authorizations or pre- determination requests for both medical and pharmaceutical benefits. * Meet the performance goals established for the position in the areas of compliance, efficiency, call quality, member satisfaction, first call resolution, punctuality, and attendance. * Always maintain a professional level of service to members. * Always maintain confidentiality of information. * Consistently support the Alliance's approach to Service Excellence by adhering to established department and company standards for all work-related functions. * Interact positively with all Alliance Departments. * Accurately and consistently document (electronic database) and resolve Exempt Grievances (any expression of dissatisfaction that are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment and that are resolved by the next business day following receipt). * Process MS Dept projects * Serve as a back-up to manage the escalated calls. * Perform other duties as assigned. ESSENTIAL FUNCTIONS OF THE JOB * Contacts: Receive, manage, and document telephone calls, emails, and other sources of contacts from members, potential members, and providers, and explain health plan benefits and plan rules. Describe the types of services the Alliance offers to the Member within the managed care system. Provide clarification about issues regarding patient and physician rights and how the plan operates. * Conflict resolution: Resolve member problems/conflicts by convening with other departmental staff as needed. * Member communications: Create and/or mail appropriate member materials and communications as needed. * Computer: Perform ongoing data entry which assists in the maintenance of the Member Services department database to ensure data integrity. * Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls. PHYSICAL REQUIREMENTS * Constant and close visual work at desk or computer. * Constant sitting and working at desk. * Constant data entry using keyboard and/or mouse. * Constant use of multi-monitor setup * Frequent use of telephone and headset. * Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. * Frequent lifting of folders, files, binders, and other objects weighing between 0 and 30 lbs. * Frequent walking and Standing Number of Employees Supervised: 0 MINIMUM QUALIFICATIONS: * Bachelor's degree or equivalent experience preferred. * High school diploma, GED required. * The ability to speak and understand-bilingual: Spanish/English, Cantonese/English, Vietnamese/English, Tagalog/English are required as designated. * A bilingual proficiency exam will be administered to ensure the candidate possesses the appropriate skill level to meet requirements. The successful candidate must score 90% or higher. MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE: * Minimum one year of direct customer service experience. Call center experience and managed care experience a plus * Experience determining eligibility for financial assistance, insurance benefits, unemployment and/or other social services programs. * Demonstrated knowledge expert of AAH Member Services policies and procedures * Consistent record of meeting, maintaining, or exceeding monthly Departmental performance metrics. * Consistent track record of documenting Service Requests accurately and clearly and monitoring open Service Requests to ensure responses and closure. * Consistent record of high quality of work as demonstrated through call and documentation auditing, appropriate Call Disposition coding, as well as an overall acceptable monthly Member Satisfaction Survey result as assessed by Member Services Quality Specialist, MS Trainer and Member Services Supervisor. * Demonstrated proficiency in current Customer Relationship Management (CRM) tool, phone system software Quality Management Solution, Pharmacy Benefits Management applications (PBM), Interpreter vendor scheduling software, delegate portal solutions and the Alliance's Member portal. * Demonstrated ability to effectively handle the department's key special projects: Member Portal Request Processing, Kaiser PTE Requests, PCP retroactive and same month requests. * Demonstrated ability to help members face-to-face in the field and/or at the Alliance offices (walk-ins). Also highly skilled at handling issues related to member bills, transportation set-up and benefit coordination with providers and pharmacy needs. SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE): * Ability to prioritize and adapt to changing situations in a calm and professional manner. * Ability to maintain composure in stressful situations. * Excellent problem-solving skills * Ability to exhibit cooperation, flexibility, and provide assistance when talking to members, providers, and staff. * Skill in basic data entry * Ability to type 40 net words per minute: multi-task * Manual dexterity to operate telephone, computer keyboard equipment. * Speak English proficiently, clearly, and audibly. * Memorize and retain information quickly; meet physical requirements * Spell correctly * Learn the policies, regulations, and rules applicable to business operations. * Follow instructions, reason clearly, analyze solutions accurately, act quickly and effectively in emergency situations; operate office equipment including computers and supporting word processing, spreadsheet, and database applications. * Excellent phone etiquette and ability to communicate clearly and concisely, both orally and in writing. * Excellent interpersonal skills with the ability to interact with diverse individuals and flexibility to customize approach to meet all types of member communication styles and personalities. * Strong verbal and written communication skills. * Demonstrated ability to quickly build rapport and respond to members in a compassionate manner by identifying and exceeding member expectations (responding in respectful, timely manner, consistently meeting commitments). * Demonstrated ability to listen skillfully, collect relevant information, determine immediate requests, and identify the current and future needs of the member. * Must be self-motivated and able to work with minimal supervision * Must be team-oriented and focused on achieving organizational goals. * Proficient problem-solving approach to quickly assess current state and formulate recommendations. * Proficient in translating healthcare-related jargon and complex processes into simple, step-by-step instructions which members can understand and act upon. * Proficient conflict management skills to include ability to resolve issues during stressful situations and demonstrating personal resilience. * Ability to work regularly scheduled shifts within the Alliance's hours of operation including the training period, with scheduled lunches and breaks, flexibility to adjust daily schedules; and to work over-time and/or weekends as needed. * Medical terminology knowledge preferred * Ability to work within a broad systems perspective * Experience in use of various computer systems software as well as Microsoft Windows, and Microsoft Suite, especially Outlook, Word, Excel. * Must have reliable and stable internet connection for remote work (50-100 Mbps download speeds). Employees who interact with members of the public may be required to be tested for Tuberculosis and fully vaccinated against COVID-19 and influenza. Successful candidates for those positions/ classifications may be required to submit proof of vaccination against influenza and/or COVID-19, a negative Tuberculosis test, or request an exemption for qualifying medical or religious reasons during the onboarding process. Candidates should not present proof of vaccination until instructed to do so by the Human Resources department. SALARY RANGE $22.88-$34.33 HOURLY 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.

The Configuration Quality Assurance Analyst I is responsible for auditing of Configuration Analyst I and Configuration Specialists on system related job functions. Performs retrospective, concurrent, and special configuration audits. Collaborates with Configuration Technical Development and Quality Assurance teams to identify audit trends and staff training. Responsibilities Collaborate with Lead Auditor and training team to identify audit trends and staff training needs Perform monthly retrospective audits of Configuration Analyst I and Configuration Specialist staff Perform concurrent audits of Configuration Analyst I and Configuration Specialist staff Perform monthly retrospective audits of system configuration Provides feedback to Configuration management team on staff performance relating to accuracy of work or system enhancements Document audits and report all audit outcomes for Configuration management review Writes and/or provides input on Configuration department procedures Maintain current knowledge of assigned configuration areas of responsibility, and related Partnership Policy and Procedure, Medi-Cal Provider Manual, Title 22 regulations, CMS Medicare regulations, and Knox Keene regulations Maintain current knowledge of all Partnership processes that impact Configuration department responsibilities including but not limited to: Claims, Member Services, Finance, Pharmacy, Health Services, Provider Relations, IT-EDI, IT- Amisys. IT- Webteam processes Support design and enhancement to Configuration audit process Support configuration related testing activities Support configuration related project activities Other duties as assigned. Qualifications Education and Experience Bachelor's degree in related field preferred. Experience with AMISYS Advance or other claims payment system, fee schedules, and procedure/diagnosis code tables preferred. Prior training and/or auditing experience desirable. Minimum three (3) years of healthcare experience preferably in a managed care environment; or equivalent combination of education and experience. Special Skills, Licenses and Certifications Knowledge of AMISYS Advance or other claims payment system preferred. Knowledge of managed care concepts, policies, and procedures. Ability to understand, interpret, and apply knowledge of regulatory requirements. Ability to quickly acquire in-depth knowledge of Partnership systems, software, applications, processes, and managed care issues. Working knowledge of MS Windows related applications and experience with database applications, typing, and 10-key use. Performance Based Competencies Strong written and oral communication skills with ability to interpret and understand technical requirements. 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 lift 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: $ 77,430.47 - $ 96,788.08 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: 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 Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 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.

To oversee the appropriateness and quality of care delivered through Partnership HealthPlan of California and for the cost-effective utilization of services. Responsibilities Performs Treatment Authorization Request (TAR) review and appeals to determine medical necessity, appropriateness of services, interprets benefits and limitations, and reviews claims, which are questionable in dollar amount or volume or scope of services. Assures that care is at all times at an acceptable level of quality. Confers with and counsels participating physicians who have questionable patterns of utilization. Coordinates with Utilization Management department managers and directors to provide daily support and appropriate direction to staff on issues pertaining to UM. Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment guidelines. Serves on Quality/Utilization Advisory Committee, Pharmacy & Therapeutics Committee, Credentials Committee and Internal Quality Improvement Committee as requested by the Chief Medical Officer/ May work with community provider committees and Advisory boards on medical issues and policies. Reviews potential quality issues and determines their appropriateness for review by the Peer Review Committee. Advises the Grievances and Appeals Department on preparing for, and testifying, in State Fair Hearings. Engagement of the Partnership provider network to improve quality of care and member experience. Performs Pharmacy Authorization Request (PARx) review and appeals to determine medical necessity and appropriateness of prescribed medications. Other duties as assigned. Qualifications Education and Experience Medical Doctor or Doctor of Osteopathy, plus completion of a residency program. Minimum of 5 years post-residency clinical experience. Special Skills, Licenses and Certifications California Medical License. Board Certification in an American Board of Medical Specialist Specialty. Understanding of outpatient clinical practice and hospital medicine. 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 Advanced computer skills, including proficiency in multiple software applications including Microsoft Office. Ability to present data in local, concise manner. Ability to analyze complex medical issues. Work Environment And Physical Demands More than 50% of work time is spent in front of a computer monitor. Must be able to work in a fast paced environment and maintain courtesy and composure. 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 $ 260,773.07 - $ 352,041.65 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: Health Services Reports To: Director, Behavioral Health The Behavioral Health Services Personal Care Coordinator is responsible for supporting and coordinating internal and external resources for members referred to case management programs for all lines of business 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. * Work with case managers to assist members navigating the healthcare delivery system and home and community-based service to facilitate access related to medical, psychosocial and behavioral health benefits and services. * Monitor and respond to inbound case management inquiries and referrals and escalate to clinical staff, as appropriate. * Provide outreach to members to facilitate timely completion of Health Risk Assessments (HRA's) by telephone, mail or in person, as needed. * Support the coordination of member care with PCP, Specialists, Behavioral Health and Long Term Services and Supports providers and other stakeholders to assist member to achieve or maintain a level of functional independence which allows them to remain at home or in the community. * Assist with coordinating the involvement of the interdisciplinary care team (ICT) members including the member and/or their family/responsible party to implement the individualized care plan (ICP). Oversee correspondence related to care plans. Document ICT meetings following SCFHP policies and procedures. * Support successful transition of care for members who move between care settings by coordinating services for medical appointments, pharmacy assistance and by facilitating utilization review. Assist to ensure follow up for psychiatric hospitalizations for members to obtain psychiatric/behavioral health care. * Follow UM policies and procedures for new authorization requests. May conduct data entry into the authorization software application system and determination notification to member and/or provider in accordance with regulatory timeframes. * Produce and distribute internal reports that may include QI reports, member admission and discharge reports and external stakeholder reports, as appropriate. * 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. * Maintain knowledge of current resources in communities served by our members to support case management goals. * Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing. * May support and conduct non-clinical training in accordance with training guidelines and protocols; provide input and develop training and reference materials. May develop Behavioral Health department orientation binder and assist with onboarding of new employees. * Identify issues and trends (data, systems, member, provider, other) as well as general departmental questions/concerns; report relevant information to management; and make recommendations to improve operations. * Collaborate with team members on improvement efforts across-departments regarding quality improvement projects, optimization of utilization management, and member satisfaction. * Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training, coaching sessions and external stakeholder meetings. * Understanding of Behavioral Health and 1115 Waiver programs, including Alcohol and Drug Services and assess members for appropriate referrals into these programs. May be required to facilitate Behavioral Health Treatment (BHT) services, including identification of providers, timely access to assessment and treatment. * 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. * Bachelor's Degree in a health related field or equivalent experience, training or coursework. (R) * Minimum three years of relevant experience in a healthcare or community setting providing care coordination of health and/or social services. (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 Medicare and/or Medi-Cal benefits, community resources and principals of case management. (D) Knowledge of medical terminology. (D) * Knowledge of Santa Clara County Health and Social Services. (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) * Ability to work within an interdisciplinary team structure. (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. (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

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.

To assist and support the Director with development, implementation, and maintenance of professional, facility, and ancillary contracts for the Partnership provider network. The Contracts Coordinator II is responsible for, Contracting Department tracking, and reporting provider network activities, including of scanning contract documents, mailing or emailing network notices related to contracting, initiating contracts and supporting daily contracting activities as assigned by Director. Provide administrative support to Director as needed. Responsibilities As assigned by the Director, support daily management of provider contracting activities for clinics, safety net providers, physicians, physician groups, hospitals, free-standing facilities, ancillary, and other provider types for all Partnership programs. Assist with obtaining contract signatures, contract renewals, and amendments from CEO, COO, CFO or designee. Ensure all contracts are scanned and stored to CONTRAXX and/or internal Partnership network drives. Distribute amendments or new agreements to key departments and staff within Partnership per Partnership procedures and protocols. Process and respond to requests from external potential providers via phone or written correspondence. Monitor the contracts dept. email in-box and facilitate replies to inquiries. Respond to general questions regarding the status of contract processing. Fulfill requests for contract copies from internal and external customers as approved by Director. Support Director with contract projects and coordinate contracting activities as it relates to Plan initiatives, DHCS requirements, other Regulatory mandates, and Credentialing activities. Actively participate in workflow and process improvement activities. Assist with collating information for all regulatory projects and internal/external audits. Under direction from the Director, initiate unique Letters of Agreements (LOA) when requested. Ensure all contracts, amendments, documents are properly routed using the PR department workflow procedures or as assigned by Director. Use Partnership WorkFront, CONTRAXX or other designated software for distribution of agreements, LOAs, other contracting documents. May act as a point of contact for Contracting reports of contracting activities per PR dept. requirements for, Director, Senior Director and COO. Work closely with PR Systems, Data and Audit staff to ensure accuracy of contractual setups in Partnership systems. Monitor and track assigned contracting activities according to PR department established timelines and workflow processes. Support the ongoing maintenance of provider template contracts, in collaboration with Contract Manager and under the guidance of Director to ensure contract compliance. Follow up on outstanding contracting activities via phone or written correspondence. Attend internal network planning meetings as assigned by Director. Other duties as may be assigned. SECONDARY DUTIES AND RESPONSIBILITIES Back up to PR Contracting colleagues when needed Participate in special projects as assigned. Qualifications Education and Experience H.S. Diploma or equivalent; three (3) years of customer service experience or any combination of education and experience which would provide an equivalent background required. Bachelor's degree preferred. Prefer three (3) years' experience in a business segment servicing providers with exposure to network management or network development and managing of healthplan or payor provider agreements. Prefer experience with medical provider contracting using various reimbursement models including capitation, fee-for-service, per diem, DRG, pay for performance. Special Skills, Licenses and Certifications Requires strong oral, written and interpersonal communication skills, problem-solving skills, and analytical and critical thinking skills. Knowledge of managed care, contracting, policies, and procedures. Requires intermediate to advanced skills with MS Word, Excel, Powerpoint and Visio. Must be computer proficient. Eye for detail and accuracy. Performance Based Competencies Excellent organization skills with ability to prioritize assignments, maintain effective filing systems, and meet deadlines. Ability to use good judgment and handle sensitive issues with tact and diplomacy. Work Environment And Physical Demands Ability to use a computer keyboard and 10-key calculator. More than 80% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects weighing up to 30 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 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 Partnership 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 Partnership 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: 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: Non-Exempt Department: Health Services Reports To: Health Services Management Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 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.

Onsite : Full Time Onsite 1240 South Loop Road, Alameda, California. Applicants must be a California resident as of their first day of employment. PRINCIPAL RESPONSIBILITIES: Under the Supervision of the Member Service Supervisor DSNP, a Member Service Navigator III - DSNP, you will respond to health plan member inquiries by telephone and other communication channels, providing members or prospective members with comprehensive support regarding health plan benefits and services. You will act as the primary point of contact for prospective members, and current members/authorized representative, delivering prompt, accurate, and courteous assistance, whether for general inquiries, concerns, or information requests about health care programs, services, eligibility, or benefits. Additionally, the MS Navigator will be cross trained to serve as a Member Service Representative (MSR) or Member Liaison Special BH I (MSR, MLS BH) during periods of high call volume or staffing shortages, ensuring consistent member support and education. Principal responsibilities include: * Adhere to established guidelines, call scripts, and resources to address member inquiries, including maintaining the confidentiality of member information and complying with HIPAA and other relevant regulations. For non-routine inquiries, leverage available resources and expertise to resolve issues outside standard protocols. * Know, understand and comply with internal policies and procedures to ensure compliance with CMS Part C Star Ratings Measures (CMS Secret Shopper Calls), DHCS, DMHC and NCQA standards. Attend and actively participate in regular departmental meetings, team meetings, training sessions, and coaching sessions as applicable. * Conduct member outreach such as welcome calls and targeted member outreach calls as assigned. * Cross training in various tasks as requested to ensure the continuity of operations within the Member Services department and other departments. * Develop and proactively maintain up-to-date knowledge of relevant quality, regulatory, and organizational guidelines. * Educate members and prospective members about eligibility, benefits, and our provider network. Assist members in selecting or changing their primary care physician (PCP) and provide accurate information about available providers and effective dates for PCP assignments. * Ensure documentation is accurate and in compliance with regulatory requirements and accreditation standards. * Handle inbound and outbound calls and other communications in a high-volume environment, providing excellent member service and professionalism following established policies and procedures and meeting performance and quality metrics. * Intake, handle (first call resolution), and coordinate member grievances, appeals, and claims/billing issues, escalating to the Grievance and Appeals, Pharmacy, or UM department when necessary. * Maintain health information confidentiality and follow information privacy and security best practices. * Meet the performance goals established for the position in efficiency, call quality, member satisfaction, first call resolution, punctuality, compliance and attendance. * Participate in and represent the company professionally at health fairs, community partnership meetings, committees, and coalitions. * Perform problem research, use analytical skills, and effectively influence positive outcomes. * Proactively seek opportunities to improve processes and enhance the overall member experience. * Resolve concerns accurately, promptly, professionally, and with cultural competence; ensure that explanations are appropriate to the member's level of understanding and knowledge. * Use listening skills and judgment to appropriately categorize and accurately document all interactions and follow-up actions regarding member communications and activities per established guidelines. * Use strong professional judgment to determine when to escalate member inquiries to other departments. Share important information and collaborate with teams to resolve issues, including referring members to health services for care coordination and guiding providers to specialists for help with complex claims or questions. * When applicable, refer members to appropriate community partner agencies based on their specific needs, including Behavioral Health and Recovery Services, Aging and Adult Services, Legal Aid, Human Services Agency, and HICAP. * Maintain knowledge base of desk level procedures and stay up to date with training materials to meet regular productivity and quality departmental standards. * Understand, know, comply with expectations for each case type: care coordination, complex, transitions of care etc. * If appropriate, work with state and federal eligibility and enrollment staff/vendors to assist in continuity in enrollment. * Help guide and educate members about maximizing the value of their health plan benefits and choosing a primary care provider. * Contact care providers (doctor's offices) on behalf of the members to assist with appointment scheduling or connections with internal departments for assistance. * Assist members in navigating AAH website while encouraging and reassuring * Assist members in person * Complete other duties and special projects as assigned. * Productivity: o Maintain adequate passing score on monthly productivity audits, including call volume and documentation volume. o Demonstrate availability to accept incoming calls during normal business hours except when approved by leadership in advance. * Quality and Accuracy: o Maintaining adequate passing score (95%) on monthly audits * Compliance: o Maintaining adequate passing score (95%) on monthly audits * Attendance and Punctuality: o Maintaining adequate passing score on monthly audits ESSENTIAL FUNCTIONS OF THE JOB: * Telephone: Complete and document all telephone calls to members and explain health plan program benefits to Alliance members. Describe the types of services the Alliance and other community partners offer. * Computer: Accurately maintain member database to ensure data integrity. * Meetings: Participate in departmental and non-departmental meetings and other scenarios. * Perform writing, administration, data entry, analysis, and report preparation. * Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls. * Maintain adaptability and flexibility; engage in cross-training to acquire skills and knowledge for various responsibilities. * Apply cross-training methods to minimize call transfers and escalations, supporting resolution during initial contact and enhancing customer satisfaction. * Serve as the main contact across several Alliance Member Services channels, including phone queues, in-person engagements, mail, email, and the online member portal. * Respond to inquiries by answering calls and providing precise information regarding Alliance plans, benefits, eligibility, and enrollment procedures. * Manage concerns and complaints by resolving complex member issues and de-escalating challenging situations, following federal, state, and contractual guidelines while maintaining customer service standards. * Investigate complex issues and ensure their resolution. * Exhibit thorough understanding of coverage and benefits to support appropriate service usage per DHCS, DMHC, CMS, and NCQA guidelines. * Attend required departmental and non-departmental meetings. * Present information about Alliance and community partner services in a clear and culturally respectful manner. * Follow AAH policies and procedures and adhere to DMHC, DHCS, CMS, NCQA regulatory standards, including PHI/HIPAA compliance. * Develop solutions to challenges and opportunities as they arise. * Remain informed about available health plans and AAH's benefits to assist members accurately. * Communicate both verbally and in writing effectively with a diverse audience. PHYSICAL REQUIREMENTS: * Constant and close visual work at a desk or a computer. * Constant sitting and working at a desk. * Constant data entry using multiple monitors, keyboard and/or mouse. * Frequent use of telephone headset. * Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. * Frequent lifting of files, binders and other objects weighing between 0 and 30 lbs. * Frequent walking and standing. EDUCATION OR TRAINING EQUIVALENT TO: * High School Diploma or GED required. * Bachelor's degree or combination of education and equivalent work experience which would provide the required knowledge, skill and abilities may qualify. * Two years of experience in behavioral health, community services, or other social services setting are required. * Experience in working with children diagnosed with ASD or ABA services preferred. * Customer service: call center experience preferred. * Managed Care, HMO, Medi-Cal/Medicare, and health services experience preferred. MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE: * One year's experience in triage, intake or care coordination. * 2 years' experience in Customer Service or call center role, member facing, preferably in a health care or public-sector setting. * 2 years' recent experience with managed care plans, Medi-Cal and Medicare programs, and working with underserved populations. SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE): * The ability to speak and understand-bilingual: Spanish/English, Cantonese/English, Mandarin/English, Vietnamese/English, Tagalog/English, Arabic/English, Farsi/English are required as designated. * A bilingual proficiency exam will be administered to ensure the candidate possesses the appropriate skill level to meet requirements. The successful candidate must score 90% or higher. * Fluency in English required. * Proficiency in correct English usage, grammar, and punctuation. * Demonstrates telephone etiquette and patience. * Able to communicate and collaborate with a variety of providers and individuals. * Preferred experience working with individuals with complex health needs. * Preferred experience with de-escalation techniques. * Preferred completion of AHIP's Medicare + Fraud, Waste, and Abuse (MFWA) training. * Preferred experience in crisis intervention and mental health services. * Experience in Utilization Management, Case Management, Care Coordination, or Telephonic Case Management is beneficial. * Familiarity with state and federal insurance programs is advantageous. * Knowledge of Alameda County community resources, Medicare, Medi-Cal, HICAP, Health Care Options, and Social Services. * Basic understanding of medical concepts, including the ability to identify medical and social risk factors, knowledge of chronic disease conditions, and familiarity with common treatment options. * Experience triaging crisis calls from members and escalating when necessary. * Ability to work assigned shifts during Alliance operating hours, including the training period, with designated lunch and break times, and flexibility for schedule adjustments, overtime, and weekend work as needed. * Experience in assessing callers' needs and efficiently directing them to the appropriate individual or department. * Strong computer and typing proficiency * Proficient experience in Windows including Microsoft Office suite. * Knowledge of Health insurance and medical terminology, call center best practices and quality metrics. * Good analytical and interpretive skills. * Strong organizational skills, proactive and detail oriented. * Sensitivity to a diverse, low-income community. * Excellent critical thinking and problem-solving skills. * Ability to act as a resource. * Excellent presentation, customer service and delivery skills. * Experience in providing support to members enrolled in a Medicare Advantage plan designed for individuals eligible for both Medicare and Medicaid, by answering questions regarding benefits, claims, care coordination, and addressing any concerns they may have regarding their healthcare needs preferred * Demonstrate understanding of complex medical and insurance policies related to dual eligibility. * Demonstrate outstanding service to identify the source of the caller's issue and work to resolve the inquires in a timely and professional manner * Familiarity with Alameda County resources a plus. * Familiar with quality metrics relevant to a call center and best practices for achieving them. * Ability to prioritize and adapt to changing situations in a calm and professional manner. * Ability to maintain composure in stressful situations. * Ability to type 40 net words per minute: multi-task * Demonstrated ability to listen skillfully, collect relevant information, determine immediate requests, and identify the current and future needs of the members. * Must be self-motivated and able to work with minimal supervision. * Must be team-oriented and focused on achieving organizational goals. * Proficient in translating healthcare-related jargon and complex processes into simple, step-by-step instructions which members can understand and act upon. * Proficient conflict management skills to include ability to resolve issues during stressful situations and demonstrating personal resilience SALARY RANGE $30.26 - $45.40 Hourly 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.

This position will assist in the management of hardware, software and licensing. Additionally they will work to ensure all procedures are followed in the purchasing of hardware, software and licenses. The person in this position will analyze system data, prepare purchase orders, solicit bid proposals and review requisitions. This position will ensure all IT purchases are completed in a timely manner, in compliance with current Partnership HealthPlan of California (PHC) purchasing and contracting policies, and in alignment with IT and PHC strategic plan. This position will also work with the Chief Information Officer (CIO) and/or designee in the review of licensing for all hardware and software projects. A key goal when working with representatives from across the organization will be to assist in the development of an approved and evolving multi-year IT projects roadmap that aligns with IT and PHC strategic plan, department capabilities and goals. Responsibilities IT Project Portfolio Management Review software requests to determine if functionality is already available and that they are aligned with IT Department's strategic plan. Annually review PHC's software portfolio ensuring that it is alignment with IT and PHC strategic plan. Assist CIO in the review of project budgets for completeness, reasonableness to ensure all anticipated costs are included in the annual budget. Assist CIO in the development of the annual budgets. Review IT governance policies related to data management, software, hardware usage, etc. to ensure that the policies are up-to-date and understood by all employees. Work with CIO or delegate to ensure governance of data, software, testing and other practices are being followed and reviewed for improvement. Assist in the development and implementation of an annual security plan. Assist in the development of a Security SharePoint site that aligns with security policies and HHS guidelines. Review and ensure documentation is maintained according to security policies and HHS guideline. Software/Hardware Contracts and Licensing Participate with the Chief Information Officer (CIO) and/or designee in the development and negotiation of new software and hardware contracts. Under the supervision of the Chief Information Officer (CIO) and/or the Director IT Operations (Ops), assist in the review and negotiation of licensing for all hardware and software. Work with vendor, CIO and/or Director of IT Ops to ensure software and hardware licenses are up-to-date in the most cost efficient manner while meeting the needs of the organization. Annually review and evaluate current software, hardware and consulting contracts for accuracy, potential adjustments and determine if they are meeting the current and future needs of the organization. Review invoices to ensure that they are in compliance with the existing contract(s) and are accurate. Purchasing Assist in IT purchasing to ensure all IT purchases are completed in accordance with current PHC purchasing, accounting, contracting and IT policies. Oversee and review all purchase order requests, ensuring that the documentation is complete, and submitted for approval in a timely manner. Review contract request submissions to Non-Provider Contracting for approval. Ensure that the documentation is complete, including Business Associate Agreement (BAA), Nondisclosure Agreement (NDA), Master Service Agreement (MSA), Scope of Work (SOW) and required budget information, and submitted in a timely manner for approval. Participate in contract discussions and negotiations with vendor, Non-Provider Contracting, legal, requestors and others. Ensure all hardware and software requests are reviewed and submitted for approval in a timely manner. Work with the requestor, accounting, Non-Provider Contracting and others to resolve any issues with purchase order and contract request. Asset Tracking Collaborate with Facilities to ensure all IT hardware is being tracked in accordance with policy FIN 203 - Fixed Asset Inventory (FAI) Policies. Develop and oversee hardware and software inventory system for all other IT assets not tracked in the FAI system. Infrastructure Collaborate with Non-Provider Contracting to ensure all hardware, and software maintenance agreements are being tracked. Ensure costs are aligned with capital and operating expenditure budgets. Audit/Analysis Provide support to Finance, Compliance and other departments for both internal and external audit requests or informational needs. Prepare and monitor budget forecast for the IT hardware, software, project, consulting, and capital budgets. Report any anticipated overages to the CIO. Make recommendations to the CIO to eliminate or mitigate any overages. Other duties as assigned. Qualifications Education and Experience Bachelor's degree preferred, 2 + years preparing invoices and other financial information. 2 + years working with IT contracts and inventory management. Special Skills, Licenses and Certifications PMP Certification or equivalent experience is a plus. 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 verbal and written communication skills, Excellent critical thinking and problem solving skills, Excellent soft-skills greatly preferred, e.g. adaptability, emotional intelligence, perseverance, active listening, Mindfulness Effective negotiating, consulting & coaching skills, Prior experience leading diverse and collaborative relationships across multiple teams, Must demonstrate strong analytical, reasoning and problem solving skills. Work Environment And Physical Demands Ability to use a computer keyboard. More than 90% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift reports, manuals, stocking of supplies, weighing up to 50 lbs. Position includes frequent, repetitive motion including computer typing, sitting/standing for most of the day. 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: $93,690.86 - $117,113.58 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: 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.

The Senior Healthcare Data Analyst I contributes to the overall success of the organization by developing analytic solutions that support activities related to health services utilization management, care coordination, quality improvement and population health. Through analyzing patient claims, member enrollment, and other data, the Senior Healthcare Data Analyst participates in identifying progress, performance and opportunities for improvement on programs, quality of care, patient experience, and other metrics. This position requires a thorough understanding of healthcare data and workflows, combined with an extensive experience working with large data sets, conducting data analysis, including standard statistical software (SAS), and creating reports using Tableau. Responsibilities Works collaboratively with business partners, other analysts, and IT to gather and integrate data from disparate sources. Responds to ad hoc data requests from business units and leadership Assists in design and development of data collection strategies, aggregation, analysis, and reporting to ensure data integrity and enhance information value. Participates in design and interpretation of data analyses; provides recommendations for improvement of data quality and reporting. Helps build, manage, and/or enhance predictive models Assesses reporting and automation requirements and develops appropriate solutions. Maintains in-depth knowledge of health plan operations, including claims processing, utilization management, quality improvement activities and pay for performance programs. Critically analyzes data, draws conclusions and effectively articulates results. Presents data and conclusions to non-technical audience; uses data visualizations and summaries to highlight key findings. Creates and maintains thorough and consistent documentation of programs used to create reports. Manages and prioritizes workload while meeting deliverables and expectations. Works autonomously and collaboratively with report requestors, providing guidance to define report requirements and validate results. Works collaboratively across departments to understand and meet the organization's analytic needs. SECONDARY DUTIES AND RESPONSIBILITIES Performs other assigned or needed activities required to assure success of the organization. Participates in special projects as needed. Performs other duties as assigned. General Traits Passionate about data, willing to acquire new skills and knowledge, flexible, self-motivated, and very curious. Creative problem-solver, critical thinker, independent worker, data-driven mentality. Communicates clearly and directly, relates well to others, engages people, provides and seeks feedback, articulates clearly, actively listens. Qualifications Education and Experience Bachelor's degree with concentration in health informatics, health administration, public health, computing, epidemiology, statistics or related field, Master's degree preferred. Minimum four (4) years of experience in data analysis and reporting. Knowledge of major health plan operations: healthcare claims processing, membership, provider, and benefits; or equivalent combination of education and experience. Excellent knowledge of data collection, analysis, statistics and data presentation with experience in data mining techniques and procedures. Experience using statistical packages for analyzing large data sets, SAS and/or SQL a plus. Experience working with administrative data, ideally health care data (Medicaid data a plus). Understanding of health data formats including claims, lab and pharmacy. Knowledge of clinical coding systems (e.g., ICD9, ICD10, CPT). Special Skills, Licenses and Certifications Proficiency in inferential and predictive statistical analysis. MS Office, Excel, SQL, SAS, Tableau. Ability to present complex information in an understandable and compelling manner. Performance Based Competencies Ability to quickly acquire in-depth knowledge of various systems related to claims processing, membership, provider, and benefits at Partnership. Strong written and oral communication skills with ability to interpret and understand technical requirements. Excellent analytical skills to troubleshoot and resolve data issues. Must be highly organized and proficient at multi-tasking. Must be willing and able to provide gracious assistance to users, providers, and other constituents of Partnership. Work Environment And Physical Demands More than 50% of work time is spent at a video display terminal. 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: $103,059.95 - $133,977.94 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.

This posting is for one position and will be filled as an Application Developer I, Application Developer II or Application Developer III depending on the candidate's qualifications and experience. FLSA Status: Exempt Department: Information Technology Reports To: Manager, Application Development Location: San Jose, CA Salary: Application Developer I - $85,740 - $128,610 Application Developer II - $98,601 - $147,902 Application Developer III - $111,168 - $172,310 Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521. GENERAL DESCRIPTION OF POSITION Application Developer I - Designs, develops, implements and supports small-scale, basic in-house and vendor applications and interfaces, including the accurate data exchange between SCFHP and trading partners in support of SCFHP objectives and regulatory compliance. Application Developer II - Designs, develops, implements and supports small to medium scale, basic to moderate, in-house and vendor applications and interfaces, including the accurate data exchange between SCFHP and trading partners in support of SCFHP objectives and regulatory compliance. Application Developer III - Designs, develops, implements and supports small to large scale, basic to complex in-house and vendor applications and interfaces, including the accurate data exchange between SCFHP and trading partners 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. * Maintain existing and develop new applications to support organizational business needs. * Utilize data analysis techniques and queries to support internal business functions through the generation of reports. For the Application Developer III this also includes the development and maintenance of data warehouse. * Review existing basic processes (Application Developer I) or basic to moderate process (Application Developer II) or basic to complex processes (Application Developer III), and recommend new or improved solutions that increase efficiency and accuracy and implement those solutions. * Assess and troubleshoot small (Application Developer I) or small to medium scale (Application Developer II) or small to large scale (Application Developer III) production issues related to performance, data errors, and process failures by reviewing error logs, source code, and applicable data to identify, recommend and implement solutions. * Collaborate with business analysts, other developers and business users through the project life cycle to gather and understand requirements, determine best solutions, test solutions and demonstrate functionality end users. * Actively participate in design reviews and provide input to other developers to ensure quality solutions are developed, working with the Application Developer Lead and Manager as needed. * Responsible for following the SCFHP Project Life Cycle, Software Development Coding Standards, and Change Control Management policies and procedures. * Create technical requirements based on review and analysis of requirement specifications supplied by Business Systems Analysts and/or business users. * 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 training/experience. (R) * Application Developer I - One year of experience in application development. (D) Application Developer II - Minimum two years' experience in application development (R) * Application Developer III- Minimum four years' experience in application development (R) * Applicable software development certifications. (D) * Application Developer I - Training or hands-on experience with SQL programming, MS SQL database development, and T-SQL query generation. (R) Application Developer II -Minimum one year of experience with SQL programming, MS SQL database development, and T-SQL query generation. (R) * Application Developer III - Minimum three years' experience with SQL programming, MS SQL database development, and T-SQL query generation. (R) * Application Developer I - Knowledge of MS SQL Business Intelligence tools (SSRS, SSIS, SSAS) or other enterprise business intelligence software. (D) Application Developer II - Minimum one year of experience with MS SQL Business Intelligence tools (SSRS, SSIS, SSAS) or other enterprise business intelligence software.(R) Application Developer III - Minimum three years' experience with MS SQL Business Intelligence tools (SSRS, SSIS, SSAS) or other enterprise business intelligence software. (R) * Application Developer I - Knowledge of any of the following applicable languages/platforms:.NET, PERL, Java, SAS, VB, C++, or other modern programming language or related software. (R) Application Developer II - One year 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) * Application Developer III - Three years' experience with any of the following applicable languages/platforms: .NET, PERL, Java, SAS, VB, C++, or other modern programming language or related software. (R) * Application Developer I - Knowledge of, or experience with, healthcare management information systems. (D) Application Developer II - Minimum one year of experience with healthcare management information systems. (R) * Application Developer III - Minimum three years' experience with healthcare management information systems. (R) * Application Developer I - Experience with the design and development of EDI solutions that meet HIPAA X12 standards. (D) Application Developer II/III - Experience with the design and development of EDI solutions that meet HIPAA X12 standards. (D) * Knowledge of database concepts and data processes in order to understand, develop, analyze and support various new projects and make recommendations for improvements to existing processes. (R) * Ability to document code and processes. (R) * Ability to create and follow technical specifications (R) * Ability to analyze data. (R) * Application Developer III - Ability to create and restore database backups, performance monitoring and query tuning. (R) * 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 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; * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; * 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; * 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; * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; * Emotional/Psychological 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.

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.