CommUnityCare
JOB SUMMARY: The Director of Risk Adjustment is responsible for the strategic design, implementation, and oversight of CCOK’s risk adjustment program for both ACA and Medicare Advantage businesses. This individual will coordinate with various areas including IT, Healthcare Economics, Finance,…
JOB SUMMARY: The Provider Performance Specialist plays a key role in strengthening relationships between the health plan and its provider network by offering education, support, and guidance on performance improvement initiatives. This position collaborates closely with internal clinical and reporting…
JOB SUMMARY: The Claims Examiner is responsible for examining claims that require review prior to being adjudicated. The examiner will use their resources, knowledge and decision making acumen to determine the appropriate actions to pay, deny or adjust the claim.…
JOB SUMMARY: Responsible for providing customer service support for behavioral health benefits, directing members to appropriate in network services, processing prior authorizations according to CMS and State regulations, sending out provider faxes well as member letters, and resolving behavioral health…
JOB SUMMARY: This position works under the Marketing Department’s Broker Relations and Market Development team. Employee must work collaboratively across all lines of business in achieving annual membership goals by promoting the CommunityCare brand and mission to broker partners (broker…
JOB SUMMARY: The Manager, Core Administrative Systems will oversee the strategy, operations, and support of the health plan’s CAPS platform, with a strong focus on managing the migration of legacy systems to new CAPS environments. This role will sit within…
JOB SUMMARY: The Medical Review Examiner Nurse is responsible for auditing provider and facility claims. Identifying issues related to and/or participates in various projects aimed at identifying areas of non compliance and/or potential fraud, waste and abuse, as it relates…
JOB SUMMARY: The Medical Review Examiner Nurse is responsible for auditing provider and facility claims. Identifying issues related to and/or participates in various projects aimed at identifying areas of non compliance and/or potential fraud, waste and abuse, as it relates…
The Medical Review Supervisor is responsible for overseeing activities and personnel involved in the day to day operations of CommunityCare’s medical claim review program. The Supervisor guides individuals in implementing auditing and monitoring functions aimed at identifying areas of risk…
The Contract Administrator is responsible for supporting the vendor contracting process from start to finish, including preparation, review, tracking, and maintenance of vendor contracts. This role ensures contract documents are accurate, compliant, and processed in a timely manner. The Contract…
JOB SUMMARY: Responsible for supervising credentialing personnel and oversight of training. Supervise workflows and projects to support timely, efficient production. Responsible for ensuring credentialing policies and procedures are compliant with regulatory agencies and accreditation standards. KEY RESPONSIBILITIES: Provide day to…
JOB SUMMARY: The Stars Medication Adherence Specialist implements, tracks and supports new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs for providers and members in accordance with prescribed quality standards; conducts data collection, tracking and…
JOB SUMMARY: The Provider Relations Representative is the external facing liaison between the health plan and its contracted providers. This role is responsible for onboarding new providers and delivering education on health plan policies, procedures, and clinical quality initiatives, including…
JOB SUMMARY: The Sales Executive is responsible driving new business growth in our commercial health insurance line of business. The representative will drive sales by marketing and selling the company’s commercial lines of health insurance products to employer groups—small, mid…
JOB SUMMARY: Responsible for maintaining information related to Accounts Receivable, Broker Commissions and Daily Deposits. KEY RESPONSIBILITIES: Performs all A/R duties related to Broker Commissions for Commercial HMO, CCLH and Medicare including checking the calculations, updating Great Plains and the…
JOB SUMMARY: Responsible for marketing the company’s commercial products to prospective clients and for assisting in the servicing and retaining existing accounts. KEY RESPONSIBILITIES: Identifies and sells lines of business directly to potential corporate clients and through an assigned distribution…
JOB SUMMARY: Responsible for all written inquiries from members seeking resolution through the grievance and appeals process. KEY RESPONSIBILITIES: Researches member issues and prepares grievance and appeals information for each level of the appeal process. Responsible for adhering to established…
JOB SUMMARY: Responsible for marketing the company’s commercial products to prospective clients and for assisting in the servicing and retaining existing accounts. KEY RESPONSIBILITIES: Identifies and sells lines of business directly to potential corporate clients and through an assigned distribution…
JOB SUMMARY: The Analyst provides analytical support for all departments, including analysis, pricing, capitation, network and provider specific reporting. Analytical support includes creating and executing beginner and intermediate level reports and programs and programming modifications to previously written reports. The…
JOB SUMMARY: Responsible for maintaining information related to Accounts Receivable, Broker Commissions and Daily Deposits. KEY RESPONSIBILITIES: Performs all A/R duties related to Broker Commissions for Commercial HMO, CCLH and Medicare including checking the calculations, updating Great Plains and the…
JOB SUMMARY: Responsible for being the first point of contact for all membership related questions, requests and concerns and for providing outstanding service to our customers. You will answer queries regarding customer benefits, eligibility, PCPs, claims and other questions. You…