CommUnityCare Jobs

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 to provider billing practices. KEY RESPONSIBILITIES. Review claims by requesting medical records and other documents to evaluate for clinical appropriateness, coding complianc...

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, and the Clinical Auditing team in order to maximize the efficiency and effectiveness of Risk Adjustment strategy, analytics, and data reporting to CMS, as w...

JOB SUMMARY. The Controller, reporting to the CFO, leads all accounting functions and guides financial decisions by establishing, monitoring, and enforcing policies and procedures regarding Accounts Payable, Accounts Receivable, journal entries, the general ledger, investments, treasury, and statutory reporting. Protects assets by establishing, monitoring, and enforcing internal controls. Monitors and confirms financial condition by conducting au...

JOB SUMMARY. This non-clinical position supports the department by performing a broad range of clerical duties. KEY RESPONSIBILITIES. Prepares correspondence to members, providers, and facilities. Provides follow up with providers and members as needed. Reviews service requests for completeness of information. Enters information into the database, compiles data and runs reports. Receives telephone calls, answers non-clinical questions and takes i...

JOB SUMMARY. The Director Actuary will coordinate work with CCOK’s external actuaries, work closely with Marketing, Finance, Underwriting and other departments to find solutions to assist the company in achieving long-term profitable growth. The Director Actuary will have deep Health Insurance experience and a particular focus in Medicare Advantage, to direct the calculation of risk, analysis of trends, and pricing for products and services provi...

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, and the Clinical Auditing team in order to maximize the efficiency and effectiveness of Risk Adjustment strategy, analytics, and data reporting to CMS, as w...

JOB SUMMARY. Responsible for providing technical and customer service support for pharmacy benefits, processing prior authorizations according to CMS and State regulations, and resolving pharmacy related complaints. KEY RESPONSIBILITIES. Telephone support for pharmacies and members related to pharmacy benefits for the HMO product. Provides resolution for various types of phone calls including, but not limited to referral, authorization, and step ...

JOB SUMMARY. This position is a part of a team that provides support to Brokers via email and phone communication. Support is provided for billing/invoice inquiries, eligibility inquiries, claims inquiries, and benefit verification. As a Broker Support Marketing Liaison, you are expected to foster a member centric, performance driven attitude to uphold our culture and reputation for caring for our members like no other health plan can or does. . ...

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 of agents/brokers. Group market includes an emphasis on small and large group market. Must comply with provisions contained within the Sales Compens...

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 Provider Services Representative supports the internal infrastructure of the Provider Relations department by managing provider lifecycle processes and maintaining operational efficiency. This administrative role ensures timely and accurate updates to provider records, coordinates credentialing and termination workflows, and responds to routine inquiries from provider offices and internal teams. The Provider Services Representati...

JOB SUMMARY. The Employee Engagement Coordinator plays a critical role in fostering a positive and productive workplace culture by planning, implementing, and evaluating employee engagement programs and initiatives to increase employee engagement and satisfaction within the company. This role supports employee satisfaction, retention, internal communication, and organizational alignment by promoting collaboration, recognition, wellness, and feedb...