Santa Clara Family Health Plan jobs - 30 jobs

Salary Range: $130,622 - $202,465 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status:Exempt Department:Health Services Reports To:Director of Medical Management GENERAL DESCRIPTION OF POSITION The Manager of Utilization Management (UM) is responsible for the direct oversight of internal and external delegated UM functions including the development and implementation of policies, procedures and program development and related quality monitoring. In addition, the Manager of UM is responsible for supervising the Supervisor of UM to ensure that all administrative UM processes are performed in accordance with all applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Develop, implement and manage all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements for all lines of business. Develop and implement continuous analysis and quality monitoring of all policies and procedures to evaluate UM staff performance and ensure regulatory compliance, including the development and implementation of effective, measurable corrective action plans to meet targeted strategic outcomes. Ensure the integration of UM operations into other internal and external teams/departments including Quality, Long Term Services and Support (LTSS) and Behavioral Health (BH). Establish and maintain effective interpersonal relationships with all SCFHP staff, members and/or their authorized representatives, providers and other program or agency representatives. Ensure UM Committee preparedness. Attend off-site meetings. Perform other related duties as required or assigned. SUPERVISORY/MANAGEMENT RESPONSIBILITIES Carries out supervisory/management responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include: Recruiting, interviewing, and hiring. Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives. Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance. Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work. Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. Unrestricted professional RN licensure in the state of California. (R) Minimum two years of experience in a supervisory capacity in a managed care setting. (R) Understanding and/or experience with Utilization Management. (R) Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA regulatory Population Health standards. (R) Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R) Ability to use a keyboard with moderate speed and high level of accuracy. (R) Excellent written, verbal, and interpersonal communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R) Ability to comply with all SCFHP policies and procedures. (R) Ability to think and work under pressure and effectively prioritize and complete tasks within established timeframes. (R) Ability to assume responsibility and exercise sound judgment when making decisions within the scope of this position. (R) Maintenance of a valid California Driver's License and acceptable driving record in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels. Frequent computer screen exposure. EOE (function () { 'use strict'; social Share.init(); })();

Salary Range: $74,557 - $111,835 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status:Non-exempt Department:Community Based Programs Reports To:Manager, SDOH or Manager, Community Based Case Management Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 GENERAL DESCRIPTION OF POSITION The Community Based Services Specialist serves as the lead, primary contact, and liaison for developing, supporting and monitoring the network of public and community based providers and vendors delivering Enhanced Care Management (ECM), Community Supports (CS), and/or other activities, programs or special projects addressing social determinants of health. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Develop and maintain updated knowledge of community based services, and capacity across Santa Clara County and support identification and assessment of ECM and/or CS provider network gaps. Recommend for initial and ongoing needs to support ECM and/or CS delivery system and operational infrastructure including data exchange, workforce training and capacity building. Support ECM and/or CS authorization and delivery process in accordance with DHCS-developed service definitions, eligibility criteria and reporting requirements. Oversee the development and management of the ECM, SDOH and/or CS provider network including: Serve as a knowledge and resource expert for ECM, CS and/or SDOH provider network operations. Establish and manage positive and productive working relationships with all public and community-based providers and vendors delivering services to members under ECM, CS or SDOH projects. Receive, research and respond to inquiries and issues that are raised by or impacting providers in a timely fashion and in collaboration with appropriate business units. Proactively communicate and collaborate with providers to identify problem patterns, track and trend issues, prepare recommendations for potential service improvement opportunities and develop tools and processes to improve communication and other processes Oversee collaboration with internal business units, particularly Provider Network Operations, Health Services Department, Finance and Claims, regarding provider communication, training and support and to ensure payments are made in accordance with vendor agreement terms. Schedule, conduct and report on regular site visits with each provider as required and coordinate and host at least one annual meeting with providers. Conduct orientation and ongoing training and education to community service providers and office staff including technical assistance, development of presentations and other written guidance or materials, in-person sessions, webinars and/or calls as needed. Assist in the preparation of promotional materials for the public, website or newsletters. Oversee provider compliance with required ECM and/or CS trainings and technical assistance including in-person sessions, webinars, and/or calls as necessary. Establish and oversee a program for communicating and tracking ECM and/or CS provider compliance with vendor agreement scope of work, key operational and financial objectives, and quality and performance metrics. Maintain accurate and timely documentation of provider contacts in compliance with NCQA standards, DHCS, DMHC and CMS regulatory requirements. Contribute to the development of ECM and/or CS pricing including recommending changes in pricing subsystems. Support the Department Manager in generating reports and performing special projects. Troubleshoot with providers to address issues related to submission of claims and encounter data for ECM and/or CS services. Understand and track applicable regulatory and reporting requirements. Ensure accuracy and regulatory compliance for all materials or documents. Attend off-site meeting or events as necessary. Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. Bachelor's Degree in public health, social welfare or related field; or equivalent experience, training, or coursework. (R) Minimum two years of progressively responsible and direct work experience working with the essential duties and responsibilities described above. (R) Demonstrated experience leading/managing projects, initiatives, and/or leading or directing the work of others. (R) Knowledgeable in the field of home and community-based services and community resource networks and a particular interest in working to address health disparities and addressing the needs of low-income communities. A deep understanding of SDOH that impact Santa Clara County and community members. (R) Ability to think creatively and work strategically, to help develop and implement innovative solutions yielding measurable results to the organization. (R) Ability to think creatively and strategically, gather and analyze data, organize and write reports, organize work efficiently. (R) Ability to understand, interpret, and apply applicable rules and regulations, and establish and evaluate priorities. (R) Advanced working knowledge and proficient with Microsoft Suite applications, and the ability to operate all applicable software. (R) Excellent oral and written communication skills, including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments and outside entities over the telephone, in person or in writing.(R) Ability to effectively facilitate meetings and deliver information/presentations to management, regulators, or staff (R). Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) Ability to take initiative and exercise good judgment when making decisions within the scope of the position. (R) Ability to comply with all SCFHP policies and procedures. (R) Ability to perform the job safely with respect to others, to property, and to individual safety. (R) Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R) Knowledge of the community-based delivery system and managed care. (D) Project Management Professional (PMP) certification (D) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to regular contact with co-workers, managers, external partners, and vendors, in person, by telephone, and via work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) Reasoning Requirements:ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person, by telephone, and electronically, throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels. EOE (function () { 'use strict'; social Share.init(); })();

Salary Range: $66,273 - $99,409 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status:Non-Exempt Department:Grievance and Appeals Reports To:Supervisor, Grievance and Appeals GENERAL DESCRIPTION OF POSITION 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. EOE (function () { 'use strict'; social Share.init(); })();

Salary Range: $153,481 - $237,896 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status: Exempt Department: Information Technology Reports To: Director, Application and Product Development GENERAL DESCRIPTION OF POSITION The Manager of Application Development is responsible for the supervision of the application development staff in the design, development, implementation and support of in-house and vendor applications and interfaces, including the accurate data exchange between trading partners in accordance with state and federal regulatory and contractual requirements and SCFHP policies and procedures as set forth for all lines of business. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily. Supervise and mentor personnel performing design, development, implementation, maintenance, and reporting from application databases, data warehouse and data cube environments. Oversee the design, development, implementation, and maintenance of electronic data exchange in multiple formats, including EDI X 12 transaction sets specific to healthcare transactions. Oversee the development and maintenance of enterprise data warehouse. Exercise staff oversight to ensure new operations plans, policies, procedures and transition/migration plans are consistent with the overall company goals and objectives. Define and modify IT development standards, policies and procedures to ensure they remain current with business and regulatory needs. Participate in the project approval and prioritization process with other IT management and business leaders. Contribute and participate in the strategic planning process and share in the development of SCFHP vision, goals and initiatives. Develop positive relationships with managers, directors and leaders by understanding business priorities and information technology enablers. Perform other related duties as required or assigned. SUPERVISORY/MANAGEMENT RESPONSBILITIES Carries out supervisory/management responsibilities in accordance with SCFHP's policies, procedures, applicable regulations and laws. Responsibilities include: Recruiting, interviewing, and hiring. Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives. Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance. Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work. Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. Bachelor's Degree in Business Administration, Computer Science, Public Health, or related field, or equivalent training/experience. (R) Minimum five years of experience in a lead or supervisory capacity. (R) Minimum ten years of experience in application development. (R) Minimum ten years of experience, with SQL programming, MS SQL database development, and T-SQL query generation. (R) Minimum five years of experience with MS SQL Business Intelligence tools (SSRS, SSIS, SSAS) or other enterprise business intelligence software. (R) Minimum five years of programming background in any of the following applicable languages/platforms; .NET, PERL, Java, SAS, VB, C++, C#, or other modern programming language or related software. (R) Demonstrated knowledge of software development life cycle (SDLC), coding standardization, peer review and user acceptance testing. (R) The ability to effectively manage multiple projects across multiple team members, including direct reports and other IT staff members. (R) Excellent data analysis skills. (R) Knowledge of and experience with healthcare management information systems. (R) Good working knowledge of BizTalk, Sharepoint, ActiveBatch and other core integration tools and services. (D) Working knowledge of and the ability to efficiently operate all applicable computer software including a working knowledge of computer applications such as Outlook, Word and Excel. (R) Ability to use a keyboard with moderate speed and a high level of accuracy. (R) Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R) Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) Ability to maintain confidentiality. (R) Ability to comply with SCFHP's policies and procedures. (R) Ability to perform the job safely with respect to others, to property, and to individual safety. (R) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to regular contact with co-workers, managers, external partners, and vendors in person, by telephone and via work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels. EOE (function () { 'use strict'; social Share.init(); })();

Salary Range: $74,557 - $111,835 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status:Non-Exempt Department:Health Services Reports To:Health Services Management GENERAL DESCRIPTION OF POSITION 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. EOE (function () { 'use strict'; social Share.init(); })();

Title: Customer Service Claims Processor Department: Customer Service Union: OPEIU 29 Grade: 17 The Customer Service Claims Processor is focused on providing customer service via call handling to participants, beneficiaries, union locals and providers regarding eligibility, benefits and claims status in conjunction with claims processing as business needs dictate. "Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by /Role." Key Duties and Responsibilities Provides written, verbal or face-to-face customer service to members by responding to and documenting telephone and written inquiries in accordance with various Plan(s) benefits. Resolves customer inquiries and complaints in a timely and accurate manner. Escalates issues as appropriate. Processes routine medical, dental, life, Medicare, Medicaid and/or hospital claims in accordance with assigned Plan(s). Conducts research in relation to member/client/management inquiries and documents findings. Maintains current knowledge of assigned Plan(s) and effectively applies knowledge in all job functions. Consistently meets established performance quotas, including quantity and quality claims processing standards. Utilizes multiple operating platforms and portals for research and claims processing. Performs other related duties as assigned. Minimum Qualifications High School Diploma or GED. One year of experience working on the Customer Service or Claims teams. Proficiency with MS Office tools and applications. Preferred Qualifications Proficiency with conference software such as Zoom or Webex. *Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee of this job. Duties, responsibilities and activities may change at any time with or without notice. Please note that in compliance with certain state law, we are displaying salary. This rate is intended for hires into this location. Compensation: $27.00/hr Zenith American Solutions Real People. Real Solutions. National Reach. Local Expertise. We are currently looking for a dedicated, energetic employee with the necessary skills, initiative, and personality, along with the desire to get the most out of their working life, to help us be our best every day. Zenith American Solutions is the largest independent Third Party Administrator in the United States and currently operates over 44 offices nationwide. The original entity of Zenith American has been in business since 1944. Our company was formed as the result of a merger between Zenith Administrators and American Benefit Plan Administrators in 2011. By combining resources, best practices and scale, the new organization is even stronger and better than before. We believe the best way to realize our better systems for better service philosophy is to hire the best employees. We're always looking for talented individuals who share our dedication to high-quality work, exceptional service and mutual respect. If you're interested in working in an environment where people - employees and clients - really matter, consider bringing your talents to Zenith American! We realize the importance a comprehensive benefits program to our employees and their families. As part of our total compensation package, we offer an array of benefits including health, vision, and dental coverage, a retirement savings 401(k) plan with company match, paid time off (PTO), great opportunities for growth, and much, much more!

Job DescriptionExciting long-term opportunity with strong growth potential for an experienced Commercial Insurance Sales Agent/Producer. For this key role, we are seeking a dynamic and trusted business professional with an entreprenurial spirit and solid client relationship skills that enjoys working in a learning environment to master new concepts. We are looking to expand. The ideal candidate will be readily adaptable to change and direction, able to juggle multiple priorities and meet tight deadlines with an unwavering commitment to delivering excellence. This position offers a high level of responsibility and requires insurance industry experience with the ability to successfully and efficiently manage a high volume of workload. Exceptional problem solving and communication skills are essential. Individual will need strong computer skills and highly organized due to the high level of calls and marketing our agency This is an hourly plus New and Renewal Commission position. Your income is Performance based, which allows you to increase your income based upon your sales skills, work ethic, knowledge of commercial insurance products and your drive to succeed. POSITION SUMMARY Insurance Incorporated offers a dynamic collaborative work environment where individuals operate independently to provide prompt, accurate and courteous results. The Insurance Sales Agent is responsible for; Marketing, Prospecting/Qualifying and Placement of Commercial lines coverage for New Business Prospect Compile Proposals and Rating Selling and Placing of Accounts Developing and Maintaining a pipeline of new business opportunities Cross Selling Existing Accounts Renewal and Claims Reviews Respond to Incoming Sales Calls and Leads Day to day servicing of assigned accounts providing outstanding service to the client, partners, and insurance companies. Must support and promote the company's purpose, vision, and mission; always acting in the best interest of the client and firm. Must uphold and embody the corporate values of integrity, leadership, teamwork, respect, professionalism, and stability.Insurance Incorporated provides a highly competitive compensation structure including medical, dental, vision, 401k, and staff development program designed to provide growth opportunities for employees. MINIMUM QUALIFICATIONS California Fire & Casualty Broker-Agent license Knowledge of AMS360 or familiar with management systems, Acord forms, Insurance carrier rating systems Completion of IIA General Insurance Program, ARM, CPCU and/or other insurance courses highly desirable Ability to participate in continuing education for the maintenance of insurance license and personal development Excellent customer service skills including the ability to communicate effectively by phone or email Ability to work with minimal direction or assistance Proficient in use of personal computers including a strong understanding of Internet usage and the ability to quickly learn various software programs. Experience working in a paperless environment preferred Excellent oral and written English communication and figure aptitude skills as normally acquired through completion of high school level studies; college preferred Must be results-oriented with a strong sense of urgency and accuracy and demonstrate a “can-do” attitude by taking initiative, being enthusiastic, flexible, and dependable. Must be very reliable and punctual. Excellent ability to interact effectively and positively with carrier representatives and individuals at all levels of the organization. Strong organizational skills as demonstrated by the ability to work on several tasks at once with frequent interruptions while meeting sensitive time-frames. Bilingual a plus Insurance Incorporated has been serving consumers and business owners since 1958 with 7 locations throughout California and expanding. We are a Full Service Insurance agency offering Personal Lines coverages such as Home, Auto, Dwelling Fire, RV's, etc. Our Commercial division provides a full line of Commercial insurance products such as General Liability, Workers Compensation Insurance, Property, EPLI, Cyber, Commercial Auto, etc. and have direct appointments with the Nations leading insurance carriers. Our Health and Benefits Department provides Group Health, Individual Health, Dental and Life insurance. As one of the fastest growing agencies in the state, we are looking for top performers with strong goals of growth and possible management of new office in future as the company expands. We believe in STRONG CUSTOMER SERVICE and assisting our agents in growing their income year in and year out. E04JI80079a240038tj

Salary Range: $54,647 - $79,237 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change. FLSA Status:Non-Exempt Department:Health Services Reports To:Supervisor, Utilization Management GENERAL DESCRIPTION OF POSITION The Medical Management Care Coordinator I performs non-clinical supportive duties related to utilization management (UM) and care coordination for Santa Clara Family Health Plan (SCFHP) members. Routine supportive duties include but are not limited to data entry into system software applications, managing department telephone queues, and assisting with quality monitoring projects for both SCFHP lines of business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, Care Coordinator Guidelines and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Follow established Health Services policies and procedures and use available resources to respond to member and/or provider inquiries and resolve any concerns in an accurate, timely, respectful, professional and culturally competent manner Collaborate with team members on improvement efforts across-departments regarding quality improvement projects, optimization of utilization management, and member satisfaction. Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing. Assist in gathering and processing data for internal required reports and analysis. Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions. Follow UM policies and processes to the management of incoming authorization requests received through fax, mail or telephone. Identify authorization requests for line-of-business, urgency level, type of service, and assess for complete/incomplete record submission. Perform complete, accurate, and consistent data entry into system software applications in accordance with policies, procedures and instruction from UM management. Answer inbound UM phone queue calls timely to assist members and/or providers regarding inquiries involving authorizations, SCFHP program services, and/or benefits. Process written and verbal notifications of authorization determinations to members and/or providers within regulatory processing timeframes. Perform other duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. High school diploma or GED. (R) Minimum two years of experience in a health care setting in positions requiring interaction with members and/or providers. (R) Knowledge of health plan benefits, process and operations related to commercial, Medi-Cal and/or Medicare programs. (D) Proficient in adapting to changing situations and efficiently alternating focus between telephone and non-telephone tasks to support department operations as dictated by business needs. (R) Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R) Demonstrated ability to consistently meet Key Performance Indicators by participating in and achieving the standards put forth to achieve the standard requirements of the Utilization Management Department (R) Ability to work within an interdisciplinary team structure. (R) Work weekends and company holidays as needed based on business and regulatory requirements. (R) Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific UM programs. (R) Ability to use a keyboard with moderate speed and a high level of accuracy. (R) Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R) Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) Ability to maintain confidentiality. (R) Ability to comply with all SCFHP policies and procedures. (R) Ability to perform the job safely and with respect to others, to property and to individual safety. (R) WORKING CONDITIONS Duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels. EOE (function () { 'use strict'; social Share.init(); })();

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

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

FLSA Status: Exempt Department: Marketing, Outreach and Enrollment Reports To: Manager, Medicare Outreach The Medicare Outreach Agent executes SCFHP's Medicare outreach and enrollment operations to grow SCFHP Medicare enrollment in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements, and in support of organizational objectives. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. * Execute sales and outreach strategy to maximize membership growth, including meeting Medicare enrollment goals as well as individual sales and performance goals. * Ensure timely follow-up on questions, issues and concerns from beneficiaries, members, providers, community partners. * Organize and conduct sales presentations in the community and assist eligible beneficiaries to enroll, including conducting a needs assessment to best explain product offerings. * Make outbound calls to follow up and close business; receive and manage inbound enrollment calls. * Manage and execute outreach plan to providers and community based organizations to support achievement of Medicare enrollment objectives. * Seek opportunities to improve SCFHP image/visibility in the community. Contribute ideas to increase retention and enrollment. * Develop, maintain and use competitive analysis to inform outreach and retention efforts, including identifying and studying key competitors and their products, as well as related industry issues to maintain a personal awareness of competitive advantages and disadvantages; share the competitive analysis with the Marketing and Outreach teams. * Stay current on SCFHP product and competing products; stay current on CMS Medicare Marketing Guidelines and with California specific Medicare-Medicaid Plans Medicare Marketing Guidelines. * Successfully complete SCFHP required product and certification training; maintain California Life, Accident and Health Insurance License. * Identify issues and trends (data, systems, beneficiary, member, provider, other) as well as general departmental questions/concerns and report relevant information to management; make recommendations. * Address member questions, concerns, grievances, appeals or requests for services in accordance with policies and procedures, including appropriate documentation and communication with other departments. * Assist with new hire training by having new hires shadow, observe in the community, and listen to calls, in accordance with training guidelines and protocols. Observe new hires and provide feedback to the Department Manager. * Attend and actively participate in daily, weekly, and monthly departmental meetings, training 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. * Associate's Degree in a related field of study, or equivalent training/experience. (R) * Minimum two years of Medicare sales, Medicare benefits advisory work, or Medi-Cal eligibility advisory work experience. (R) * Strong presentation skills with intent to sell. (R) * California Life, Accident and Health Insurance License, or the ability to obtain within 60 days of employment. (R) * Self-directed with proven ability to assume responsibility, work independently, meet deadlines and prioritize with minimum supervision. (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) * Experience with, and understanding of, Medicare outreach and/or sales. (R) * Experience with managed care and Medi-Cal. (D) * Knowledge of current trends, practices, strategies, tools for outreach and sales, including customer relation management applications. (D) * Ability to establish and maintain effective working relationships with providers, community based organizations and program participants. (R) * Bilingual in Spanish, Vietnamese, Mandarin or Cantonese. (R) * Ability to work nights and/or weekends as needed. (R) * 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 beneficiaries, SCFHP members, providers and outside entities in person, over the telephone, or in writing. (R) * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to take initiative and exercise good judgment when making decisions within the scope of the position. (R) * Ability to 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 Duties are performed away from the office in varied community settings, and also in an office environment while sitting or standing at a desk. Incumbent's responsibilities require frequent contact with beneficiaries, members and providers, as well as interaction with co-workers and managers, in person, by telephone, and via 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 20 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS Outside of the office - community settings, meeting rooms. In the office - general office conditions. May be exposed to moderate noise levels.

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

FLSA Status: Exempt Department: Health Services Reports To: Manager, Social Determinants of Health The Housing Services Program Manager is responsible for development, implementation and ongoing management of an integrated homeless and housing strategy for SCFHP's membership. This includes managing housing and homelessness initiatives, programs and special projects, coordination of housing strategies with SCFHP's Community Supports and SDOH goals and working collectively with internal and external housing/homeless service providers and advocacy groups. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. * Create and lead both new and ongoing housing initiatives and programs by providing direction for project framing, work plan development, business case analysis, user-testing, implementation, and outcome measurement. * Develop and execute program work plans including engagement of internal departments, vendors, providers or consultants, and convening and facilitation of meetings, supporting and validating reporting data and ongoing monitoring and oversight of all program activities within specific timeframes. * Manage day to day operations for housing strategy activities including workflow, assignments, turn-around-times and follow up, referral and assistance process for member-facing departments to respond to requests from the Member, internal and/or external sources and integration with Community Supports. * Monitor and ensure workflows, ongoing programs and projects are in compliance with CMS, DHCS, DMHC and NCQA regulations and guidelines at all times. * Serves as subject matter expert and SCFHP liaison for engagement with Santa Clara County Coordinated Entry System, Continuum of Care (CoC) Board and membership, Street Medicine Team and other stakeholders engaged in developing and implementing the County's Plan to End Homelessness and housing related initiatives. * Oversee SCFHP staff utilization of Homelessness Management Information System (HMIS) including staff training, compliance with HMIS access and coordination with case management and IT teams. * Provide education on housing related ICD-10 codes, screening and identification process for network providers and delegates. * Oversee development, approval and monitoring of vendor agreements, MOUs or provider contracts with housing services providers, consultants and other vendors including budgets and tracking of invoices, payments or claims. * Develop and implement initial and ongoing training on eligibility and access for housing programs and services for new and existing Health Services staff, health and community-based network providers and delegates in accordance with organizational business requirements, and policies and procedures. * Oversee process for housing services data analytics and the completion and timely, accurate submission of reports and regulatory requirements including interface with IT, internal departments, housing provider network and the presentation of housing data via dashboard. This includes providing input and feedback on housing status screening tools, and identification of members at risk of housing insecurity. * Monitor and collaborate with management on SCFHP policies and procedures and workflows to ensure successful and compliant housing services integration and operations. * Identify, research, and resolve program issues and escalate critical issues, problems, and delays to management. * Provide regular feedback to management on status and outcome of assignments, workflows and training activities with recommendations for operational improvements. * Oversee process for developing, updating and sharing an inventory of relevant housing programs, services and community initiatives and activities that support housing needs of SCFHP members. * Participate in meetings and conference calls with regulatory agencies (i.e. Federal, State and County), NCQA, SCFHP management, delegates and vendors to obtain and capture requirements and timelines and to share best practices and experience. * Perform other related duties as required or assigned. REQUIREMENTS - Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired. * Bachelor's Degree in Healthcare, public administration, Business, social work or related field, or equivalent experience, training, or coursework. (R) * Minimum three years of experience in health, social service and/or Medi-Cal managed care setting with responsibility for program operations. (R) * Experience in developing housing/homeless policy at a local, state or federal level, and assisting special populations (seniors, people with disabilities, physical or behavioral health conditions) to secure affordable housing or homeless services through public programs. (R) * Ability to leverage knowledge and experience of affordable housing programs for identified populations at a local, state and federal level to identify and develop housing programs. (R) * Program management experience. (D) * Ability to assess training needs and methods, develop training materials and conduct trainings using a variety of techniques based on the audience. (R) * Ability to direct and manage cross-functional, multi-departmental projects to completion with minimum supervision (R) * Ability to understand, interpret, and apply applicable rules and regulations, and establish and evaluate priorities. (R) * Advanced working knowledge and proficient with Microsoft Suite applications, and the ability to operate all applicable software. (R) * Ability to use a keyboard with moderate speed and a high level of accuracy. (R) * Excellent oral and written communication skills, including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments and outside entities over the telephone, in person or in writing. (R) * Ability to effectively facilitate meetings and deliver information/presentations to management, regulators, and staff (R). * Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) * Ability to take initiative and exercise good judgment when making decisions within the scope of the position. (R) * Ability to 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) * 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 event. (R) * Experience with SQL development language and/or Tableau. (D) WORKING CONDITIONS Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to regular contact with co-workers, managers, external partners, and vendors, in person, by telephone, and via work-related electronic communications. PHYSICAL REQUIREMENTS Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: * Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R) * Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R) * Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R) * Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R) * Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R) * Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person, by telephone, and electronically, throughout a typical workday; attention to detail. (R) ENVIRONMENTAL CONDITIONS General office conditions. May be exposed to moderate noise levels.

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: Non-Exempt Department: Customer Service Reports To: Supervisor, Customer Service Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 The Customer Service Representative I answers inbound calls and makes outbound calls to support Customer Service Department operations in a manner that maintains compliance with Medicare and Medi-Cal regulatory requirements and achieves Call Center 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. * Act as the primary point of contact and liaison for SCFHP members and providers contacting the plan regarding general inquiries, concerns or requests for information. * Develop a general understanding of all member facing materials, communications and interactions and be prepared to respond appropriately to follow up calls. * Answer inbound calls and/or place outbound calls in a high call volume environment and work directly with members and providers to accurately and completely answer inquiries involving SCFHP program services and benefits. * Follow established guidelines and resources to respond to member and provider inquiries and resolve concerns in an accurate, timely, professional, and culturally competent manner. * Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary. * Educate members and providers on eligibility, and medical and pharmacy benefits and how to access services in a manner that achieves excellent service standards and maintains high customer satisfaction. * Use listening skills and judgment to appropriately categorize and accurately document all contacts and follow-up actions regarding member and provider communications and activities in accordance with established guidelines. * Appropriately handle member and provider requests through alternative channels such as e-mail, voicemail, fax, walk-in, etc. in accordance with established procedures. * Triage member and provider requests or inquiries for other departments. * Conduct member surveys as assigned in accordance with established guidelines. * Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions. * Identify member/provider issues and trends and report relevant information to management. * 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) * Minimum one year of experience in Customer Service or Call Center role, preferably within a Health Care, Public Assistance or Human Services programs. (R) * Prior experience with managed care plans, Medi-Cal and Medicare programs, and working with underserved populations. (D) * Ability to meet Key Performance Indicators by participating in and achieving the standards of the Customer Service Call Center Quality Program. (R) * Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D) * 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 Plan members and providers 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 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.

The Manager, Pension manages daily operations of multiple teams in accordance with Company guidelines, client needs, and regulatory requirements. "Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by /Role." Key Duties and Responsibilities Provides daily leadership and supervision to team consistent with management values and mission. Assigns, distributes, and monitors quality and quantity of work produced, ensuring employees are held accountable for consistently meeting quality and production requirements. Develops staff through performance management, goal setting, training, and effective employee relations. Communicates and implements changes in policies, procedures, and Plan guidelines. Ensures applicable training is delivered to support operational execution. Oversees the processing of retirement benefit applications, calculations, and payments in accordance with Plan documents and regulatory requirements. Conducts unit meetings on a regular basis to discuss updates and changes that affect operations such as new procedures, policies, or updates to Plan guidelines. Provides status and production reports on processing metrics or applications status, as needed. May perform final quality review of unusual or complicated retirement benefit calculations and balancing of monthly benefit payments. May assist in the resolution of escalated calls or questions. May attend Board of Trustee meetings to provide operational updates. Performs other duties as assigned. Minimum Qualifications High school diploma or GED. Five years of experience working in retirement benefits. Two years of experience in an operations supervisory role. Working knowledge of defined benefit plans, defined contribution plans, 401(k) plans and benefits administration systems. Exceptional team player with the confidence and integrity to earn client and internal team confidence quickly. Proven ability to recruit, lead, and motivate a team to balance staffing strength with profitability and growth. Excellent verbal and written communication skills, including interpersonal skills. Exceptional analytical and problem resolution skills; ability to exercise independent, sound judgment. Strong decision-making and organizational skills, with an attention to detail and the ability to optimize all available resources and deliver on multiple priorities. Ability to effectively manage remote employees in diverse locations and regions. Must be willing to travel as business dictates. Computer proficiency including Microsoft Office tools and applications. Preferred Qualifications College degree in a business-related field. Experience working in a third-party administrator or Taft-Hartley environment. Understanding of ERISA compliance or regulatory procedures. Work experience related to quality control or process improvement. *Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee of this job. Duties, responsibilities and activities may change at any time with or without notice. Working Conditions/Physical Effort Prolonged periods of sitting at a desk and working on a computer. Regular travel that may be overnight. May be required to work remotely. Must be able to lift up to 15 pounds at times. Disability Accommodation Consistent with the Americans with Disabilities Act (ADA) and other applicable federal and state law, it is the policy of Zenith American Solutions to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Recruiting Department at ******************************, and we would be happy to assist you. Please note that in compliance with certain state law, we are displaying salary. This rate is intended for hires into this location. Compensation: $75,000-$90,000/annually Zenith American Solutions Real People. Real Solutions. National Reach. Local Expertise. We are currently looking for a dedicated, energetic employee with the necessary skills, initiative, and personality, along with the desire to get the most out of their working life, to help us be our best every day. Zenith American Solutions is the largest independent Third Party Administrator in the United States and currently operates over 44 offices nationwide. The original entity of Zenith American has been in business since 1944. Our company was formed as the result of a merger between Zenith Administrators and American Benefit Plan Administrators in 2011. By combining resources, best practices and scale, the new organization is even stronger and better than before. We believe the best way to realize our better systems for better service philosophy is to hire the best employees. We're always looking for talented individuals who share our dedication to high-quality work, exceptional service and mutual respect. If you're interested in working in an environment where people - employees and clients - really matter, consider bringing your talents to Zenith American! We realize the importance a comprehensive benefits program to our employees and their families. As part of our total compensation package, we offer an array of benefits including health, vision, and dental coverage, a retirement savings 401(k) plan with company match, paid time off (PTO), great opportunities for growth, and much, much more!

FLSA Status: Non-Exempt Department: Information Technology Reports To: Manager, IT System Support Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521 The Telecommunications Administrator is an integral team member who is responsible for testing, planning, designing, configuring, implementing, maintaining, and supporting the telephone system, including the call center infrastructure, voicemail, and fax lines. Acting as the main point of contact, the Telecommunications Administrator performs all troubleshooting for telephone system-related issues and conducts daily monitoring of the system to ensure it performs as designed in support of SCFHP objectives and regulatory compliance. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. 1. Plan, design, configure, implement, maintain, and support the telephone/voicemail systems and fax lines, including call center infrastructure. 2. Provide daily, first-level support and maintenance of the telephone system to users, coordinate with internal departments and vendors to troubleshoot as needed, and document repairs/services in a timely manner. 3. Perform upgrades and patches in a timely manner. 4. Perform testing of the telephone system to verify system updates and to ensure quality of performance. 5. Perform scheduled system maintenance according to procedures and schedules. 6. Participate in disaster recovery planning and testing for telecom systems. 7. Assist new users with training/assistance. 8. Create desktop step-by-step procedures for day-to-day processes; review and update annually or as required. 9. Identify issues, trends, and opportunities to improve efficiency and/or quality, or to better assist users and report relevant information and recommendations to management. 10. Assist with departmental telephone projects requiring specific knowledge of the hardware and software applications related to the telecommunications network. 11. Maintain inventory of desk and cell telephones, headsets, MIFI devices, and accessories. 12. 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. Associate's degree in computer science, or related field, or equivalent experience, training, or coursework. (R) 2. Minimum three years of experience as a telephone administrator in the operation, maintenance, and repair of telecommunication systems or an internal helpdesk point-of-contact for problems with telephone systems. (R) 3. Cisco CUCM / UCCX Call Center Administration. (R) 4. Cisco scripting and configuration with call workflow and the ability to debug the system to troubleshoot issues. (R) 5. Ability to monitor the telephone services integrated voice response (IVR) system and resources to ensure 99% production uptime. (R) 6. Knowledge of Windows and Windows Active Directory. (D) 7. Ability to design, configure, implement, maintain, and support the telephone/voicemail systems and fax lines, including call center infrastructure. (R) 8. Ability to create, maintain, and update documentation about the telephone system, including the call center processes. (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. Excellent communication skills, including the ability to express oneself clearly and concisely when providing service to SCFHP users, internal departments, and outside entities over the telephone, in person, or in writing. (R) 11. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) 12. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) 13. Ability to maintain confidentiality of all HIPAA and SCFHP information and data. (R) 14. Ability to comply with SCFHP's policies and procedures. (R) 15. 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 10 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: Marketing & Communications Reports To: Supervisor, Community Resource Center (South County/Gilroy) The Community Health Worker (CHW) is committed to supporting Santa Clara Family Health Plan Community Resource Center(s) (CRC) and has a unique role in making the health of communities more equitable, especially for populations experiencing disproportionally poor health outcomes. As a trusted community member, the CHW has a deep understanding of community needs and plays an integral & multifunctional role serving as a liaison between the community and the CRC. The CHW provides outreach in community settings, screenings for Medi-Cal eligibility, and schedules one-on-one appointments for enrollment application assistance in compliance with state and federal regulatory requirements, SCFHP policies and procedures, and business requirements. The CHW supports navigation and linkages to additional resources for SCFHP health plan members and residents by referring them to the community's most appropriate programs and resources (e.g., for food, cash assistance). ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. 1. Build and maintain positive working relationships with staff, residents, community partners and governmental agencies; form and foster partnerships with safety-net and community organizations, and with government agencies. 2. Act as liaison with community residents and keep SCFHP staff informed of current community issues and interests. 3. Provide assistance for residents and families in completing new/renewal applications for Medi-Cal and for Covered California, by phone or in-person; educate residents on eligibility criteria, obtain personal information and correctly complete forms and submit all required supporting materials. 4. Represent SCFHP and the CRC at outreach events, including health fairs, enrollment events, school presentations, and community-based organization functions. 5. Contribute toward developing a community outreach planning effort to reach residents where they live, work, pray and play. 6. Assist residents and families to feel comfortable engaging with health and safety-net services while addressing their fears from personal, community, and system barriers. 7. Through outreach activities, engage designated populations about the CRC and related services, using best practices for engaging marginalized and high-risk individuals and communities. 8. Continuously expand knowledge and understanding of community resources, services, and programs to identify service gaps; work to reduce cultural and socioeconomic barriers between residents and institutions; make recommendations for programs and initiatives to address identified issues and gaps. 9. Support residents' and families' navigation and linkage to resources; conduct intake interviews to identify barriers to health and health equity; solicit residents'/families' suggestions for improving their health; using "warm hand-off," link them to appropriate resources (internal, external partners); follow up on referrals. 10. Hold workshops and gatherings with health plan members and residents to improve health awareness and healthcare access. 11. Contribute to the development and maintenance of resource information and materials. 12. Act as interpreter when supporting non-English speaking residents. 13. Organize, coordinate, and maintain records of all activities, including completing all supporting data entry. 14. Prepare daily, weekly, and monthly reports on the progress and status of service delivery. 15. Work collaboratively and effectively within a team. 16. Identify issues, trends, and opportunities to improve efficiency and/or quality, or to better assist CRC patrons, report relevant information to management. 17. Attend appropriate staff and in-service meetings. 18. 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. 1. High School Diploma or GED. (R) 2. Completion of 60-semester college units, training, or coursework. (D) 3. Minimum two years of experience working with community-based organizations supporting marginalized and high-risk, underserved populations. (R) 4. Experience integrating Motivational Interviewing and trauma-informed navigation assistance practices; ability to successfully complete Motivational Interviewing training. (R) 5. Ability to successfully complete applicable Enrollment Application Assistant training within the first month of hire and complete the renewal on an annual basis. (R) 6. Knowledge of local health and social services. (R) 7. Fluent in Spanish, Vietnamese, and/or Chinese (Mandarin and/or Cantonese). (R) 8. Have deep roots or lived experience in East San Jose or similar community, with secured and preserved trust from the community; ability to work with people of diverse socio-economic and cultural backgrounds. (D) 9. Ability to quickly build trust and rapport in interpersonal relationships, maintain appropriate boundaries when supporting residents and members, and manage challenging individuals or situations. (R) 10. Experience using Salesforce. (D) 11. Proficient in adapting to changing situations and efficiently alternating focus between multiple tasks to support Department operations as dictated by business needs. (R) 12. Experience operating general office equipment such as multi-line phones, copiers, printers, scanner, fax, and 10-key. (R) 13. Working knowledge of and the ability to efficiently learn and operate all applicable computer software, including computer applications such as Microsoft Word, Excel, Outlook, and Salesforce. (R) 14. Excellent communication skills, including the ability to express oneself clearly and concisely when providing service to SCFHP members, community residents, providers, and staff over the telephone, in person, or in writing. (R) 15. CPR/First Aid Certification or ability to acquire certification within three months. (R) 16. Maintenance of a valid California driver's license and acceptable driving record in order to drive to and from offsite meetings and events. (R) 17. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R) 18. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R) 19. Ability to maintain confidentiality. (R) 20. Ability to comply with all SCFHP policies and procedures. (R) 21. Ability to perform the job safely with respect to others, to property, and to individual safety. (R) 22. Ability to work weekends and evenings, as needed. Dependable in maintaining schedule and adaptable to schedule changes. (R) WORKING CONDITIONS The duties to perform the position include a mixture of work in the office and outside the office. Incumbents are subject to frequent standing, sitting, contact with, and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. The position also requires working outside of the office to engage the community at events, schools, and public meetings. 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, stooping, 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 30 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, mailroom equipment); 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 and community/neighborhood conditions. May be exposed to moderate or significant noise levels. May be exposed to four-season weather conditions and general external environment conditions. May be exposed to crowds of people.