CommUnityCare Jobs

JOB SUMMARY. Responsible for clinical review of utilization requests and assessment and implementation of potential coordination of care opportunities for overall membership, institutionalized populations, high risk members, and other members identified with at risk or high utilization needs. Functions as an active team member of the Utilization Management Team. KEY RESPONSIBILITIES. Performs utilization review of outpatient and ancillary service...

JOB SUMMARY. Responsible for clinical review of utilization requests and assessment and implementation of potential coordination of care opportunities for overall membership, institutionalized populations, high risk members, and other members identified with at risk or high utilization needs. Functions as an active team member of the Utilization Management Team. . KEY RESPONSIBILITIES. Performs utilization review of outpatient and ancillary servi...

JOB SUMMARY. Responsible for helping CommunityCare achieve membership growth targets by meeting or exceeding goal levels for the retention of enrolled groups and members. The incumbent is responsible for establishing positive business relationships with decision makers and decision influencers at enrolled groups, as well as with producers and consultants associated with enrolled groups. Must be willing to learn and grow into roles of increasing r...

JOB SUMMARY. Responsible for clinical review of utilization requests and assessment and implementation of potential coordination of care opportunities for overall membership, institutionalized populations, high risk members, and other members identified with at risk or high utilization needs. Functions as an active team member of the Concurrent Review Team. . KEY RESPONSIBILITIES. Performs utilization review of inpatient, post-acute, outpatient a...

JOB SUMMARY. Responsible for clinical review of utilization requests and assessment and implementation of potential coordination of care opportunities for overall membership, institutionalized populations, high risk members, and other members identified with at risk or high utilization needs. Functions as an active team member of the Utilization Management Team. . KEY RESPONSIBILITIES. Performs utilization review of outpatient and ancillary servi...

JOB SUMMARY. Responsible for auditing provider and facility claims against relevant medical records and documents. Audits verify coding accuracy, benefit payment, contract interpretation, and overall compliance with established guidelines and standards. Participates in various projects aimed at identifying areas of non-compliance and/or potential fraud, waste and abuse, as it relates to coding and provider billing practices. . KEY RESPONSIBILITIE...

JOB SUMMARY. Responsible for managing the operational and strategic aspects of the Company's Quality Improvement department, which includes the QI Program, Star Rating Program, Accreditation, and Clinical Coding and Compliance monitoring. . KEY RESPONSIBILITIES. Leads and directs processes and overall quality improvement activities for all beneficiaries. Responsible for multiple company work domains, including but not limited to. Quality Improvem...

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 will handle complaints, troubleshoot problems and provide resolutions in a professional and polite manner to ensure first contact resolution and customer satisfaction. ...

JOB SUMMARY. The Medical Director will exhibit strong expertise in utilization management and health plan leadership for our provider sponsored organization. They will have a proven track record working within a health plan environment, with a deep understanding of clinical operations, healthcare utilization, and strategies for controlling healthcare costs while maintaining high-quality care. This key role within our Clinical Operations team is p...

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 related situations that arise from calls. KEY RESPONSIBILITIES. Available and able to be telephone support part time during the hours of 8AM -5PM...

JOB SUMMARY. Responsible for leading and managing projects from planning through completion to support the organization’s strategic objectives. The role includes overseeing project milestones, managing schedules, and analyzing data to ensure successful project outcomes. Works closely with both business and IT stakeholders to address requirements, monitor progress, and provide updates, ensuring projects meet quality standards and are delivered on ...

JOB SUMMARY. 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 and/or potential fraud, waste and abuse, as it relates to provider billing practices. . KEY RESPONSIBILITIES. Provides technical expertise to MRE ...