Commonwealth Care Alliance jobs

011230 CA-Provider Engagement & Performance The Provider Delegation Performance Manager is responsible for overseeing and improving the performance of CCA's delegated partnerships programs, working with clinical community partners responsible for care management and utilization management across CCA's One Care and SCO products. This role focuses on fostering strong clinical and programmatic collaboration, effectively communicating program performance to delegated providers, and supporting the implementation of CCA's model of care and strategic objectives. The Manager leads performance evaluation and improvement efforts, including reporting and data analysis, to ensure delegated entities meet contractual, regulatory, and quality standards that optimize member outcomes and operational efficiency. This versatile position offers exposure across multiple organizational areas and involves close collaboration with program leadership, operations teams, and external provider partners. The ideal candidate will have excellent organizational and analytical skills, with the ability to engage and coordinate with diverse internal and external stakeholders to identify opportunities and drive both program-wide and provider-specific performance improvement. Supervision Exercised: • No, this position does not have direct reports. Essential Duties & Responsibilities: Performance Management: • Assume full management responsibility for all performance measure components, including end-to-end data collection, evaluation, and timely dissemination of reports to both internal teams and delegated providers. • Track and analyze site-level and program-wide KPIs to isolate gaps and identify key drivers of high and low performance. • Generate monthly and quarterly performance and administrative reports, ensuring consistency, accuracy, and timely distribution to delegated providers. This includes reporting related to contracts, regulatory, NCQA and other requirements. • Develop a deep understanding of all program measures and metrics to support delegated providers in interpreting performance data and meeting expectations. • Collaborate with providers individually to create and monitor performance improvement plans, engaging internal subject matter experts as needed and ensuring accountability for baseline performance standards. • Coordinate cross-departmental efforts to raise awareness of knowledge gaps and clarify expectations around performance metrics. • Maintain ownership of all guidance materials related to performance measures, ensuring they are accurate and up to date. • Manage the development of formal Performance Improvement Plans and prepare presentation materials such as mid-year and annual reviews and program-wide performance summaries. • Support delegated provider staff in using data tools effectively and understanding data interpretation. • Oversee administrative components related to performance management activities as needed. • Lead the program's contributions to performance measurement logic, reporting rules, exhibits, and reconciliation efforts in partnership with Business Intelligence, Finance, and Network teams. • Understand CCA's operational and contractual requirements for delegated providers and implement performance monitoring and workflow adherence plans accordingly. • Partner with Business Intelligence/Analytics teams to develop and present clinical, operational, and financial reports, proactively identifying opportunities for improvement. • Coordinate technical assistance initiatives, including convening multidisciplinary teams and leveraging specialized CCA resources to support provider performance improvement strategies. • Support broader organizational efforts to drive performance on HEDIS and STAR measures. • Schedule and facilitate regular meetings, virtual or in person, with CBOs focused on provider education, program operations, regulatory requirements, performance and care team collaboration Delegation Governance Committee Management: • Support cross-functional delegation governance Steering Committee o Manage schedule and agenda for ongoing meetings o Disseminate meeting notes o Manage all action items o Coordinate with staff managing Member communications to ensure alignment between provider and member communications o Develop routine internal reports of provider communications activities to keep both leadership and provider facing staff apprised of messaging and timelines. o Present reporting and trends to the committee o Develop and manage annual provider communications schedule Program Development and Operations Support: • Assist with preparation and response activities related to formal CMS and state audits. • Oversee special projects focused on program development, growth strategy, and new process design and implementation. • Manage operational components of new program implementations, including project planning, stakeholder coordination, and deadline management. • Collaborate across multiple internal teams and delegated providers to coordinate events, manage projects, and resolve daily operational issues. • Support program leadership in developing and maintaining CCA Policies and procedures and trainings as they relate to delegation programs. • Manages information, education and training to CCA staff, clinicians employed by CCA's clinical groups, contracted delegated entities and LTSS providers on delegation model. • Maintain reporting inventory of all reporting shared with Delegation Providers as well as received internally to support the programs • Disseminate information to Delegation Partners o Support Manager in developing guidelines, reference guides, workflows and SOPs, disseminating them to delegation entities and answering questions to ensure efficient day-to-day operations o Draft email communications under supervision of Manager o Support maintenance of materials and design of CCA Extranet/SharePoint as a key resource for information o Ongoing communication with Delegated Provider staff and CCA internal departments through email and phone calls Working Conditions: • This is a remote or hybrid role with the expectation of working according to Commonwealth Care Alliance's standard operating hours of 8:30am-5pm Monday-Friday. Required Education (must have): • Bachelor's degree Desired Education (nice to have): • Master's degree in public health, business administration, health management, social work, or a related field preferred. Required Experience (must have): • 5+ years • Experience with Medicaid and Medicare products and programs • Value-based program oversight and performance tracking • Experience working within FQHCs, Health and Human services providers or equivalent Desired Experience (nice to have): • Experience with dual-eligible (DSNP) populations preferred. • Understanding of behavioral health landscape in Massachusetts Required Knowledge, Skills & Abilities (must have): • Proven experience in program management and performance monitoring initiatives or relevant position • Working knowledge of project/program management practices • Ability to deal with a diverse and multi-disciplinary team • Excellent problem-solving and organizing skills • Strong written and oral communication skills and comfort presenting to large audiences • Ability to create and use project management materials, such as project plan, timelines, etc. and work across stakeholders to drive towards a given deadline • Skilled with data analytics and comfort with common analytics tools such as excel • Ability to have a professional presence across internal and external stakeholders and across various levels and functions • Outstanding verbal and written communication skills • Professional presence and comfort in communicating with and presenting to senior level staff, including creation of external facing presentation materials • Good knowledge of MS Office • Must have ability to learn new systems and databases that CCA implements. • Working knowledge of Medicare and Medicaid (MassHealth) • Demonstrated skills in Excel and PowerPoint • Polished, professional presentation skills in working with key provider partners and internal leaders. • Exceptional written and verbal communication skills, with the ability to translate complex information for diverse provider and internal audiences. • Ability to build and maintain positive relationships and collaborate effectively with internal and external stakeholders. • Proactive in identifying issues and developing effective solutions. • Adaptable and able to thrive in high-pressure environments, adjust to shifting priorities, and manage multiple deadlines. • Results-oriented and self-motivated, with the ability to work independently and as part of a team to meet departmental goals. • Demonstrates empathy, self-awareness, and the ability to navigate sensitive conversations diplomatically. • Must be able to work collaboratively and create an atmosphere of trust and respect within project teams and with external partners • Must be highly organized and self-directed with a proven ability to work with supervision on departmental and cross-functional projects of a diverse nature • Requires excellent interpersonal skills in order to communicate and work with staff and external partners of all skill and experience levels • Strong tactical performer • Demonstrated ability to establish and manage performance and outcome metrics. • Ability to establish and maintain positive and effective work relationships with internal staff, external vendors, and state and federal agencies • Proven skills, knowledge base and judgment necessary for independent decision-making • Excellent organizational, time-management and problem-solving skills • Must be able to exercise a high level of diplomacy to recognize politically sensitive issues • Ability to multi-task and switch gears quickly / effectively Required Language (must have): • English Desired Knowledge, Skills, Abilities & Language (nice to have): • Familiarity with care management and utilization management systems and workflows. • Experience managing delegated provider contracts and oversight programs. • Project management skills with the demonstrated ability to handle multiple projects. • Strong understanding of Medicare, Medicaid, duals program, and health plan operations, including regulatory and compliance requirements. • Demonstrated knowledge of DMH system and waiver programs helpful. • Demonstrated ability to describe and assess a simple business problem • Demonstrated ability to define a solution to a simple business problem and develop a plan for resolution Compensation Range/Target: $99,600 - $149,400 Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Primary Location: Connecticut-Farmington-9 Farm Springs Rd Farmington (10566) Job: Information TechnologyOrganization: Hartford HealthCare Corp. Job Posting: Dec 16, 2025 ITS Field Support Spec I / IS Service Delivery - (25165012) Description Work where every moment matters. Every day, more than 40,000 Hartford HealthCare colleagues come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut's most comprehensive healthcare network. The creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole, rather than a single member organization. With the creation of our new umbrella organization we now have our own identity with a unique payroll, benefits, performance management system, service recognition programs and other common practices across the system. Position Summary This position interacts with customers who have questions regarding intermediate and advanced infrastructure, hardware, software, network support and troubleshooting issues. Analyst provides first and second level support according to Information Services procedures for customers throughout the Hartford Health Care Corporation enterprise who are in need of assistance. Position reports to the Team Leader. Work from home opportunities available at the discretion of management. Key AccountabilitiesWorks effectively as a team member both within and across the hospital system to promote and integrate Information Services through communication, cooperation and collaboration. Models Hartford HealthCare Service Excellence behaviors in a fast paced environment. Answers all calls in a professional, courteous and timely manner according to department voice etiquette standards. Analyze problem and determine direction to solution solving 70% or more of assigned incidents while showing detailed troubleshooting in the incident notes. Identifies and troubleshoots problems via phone and remote access. Resolves or contacts and assigns to tier II teams in accordance within established department standards. Responsible for resolving complex problems - more in-depth knowledge of hardware, software, applications and infrastructure as defined in documentation. Coordination of work effort among groups, vendors or customers when required for ticket resolution. Create and assign work orders in addition to solving problem tickets. Create knowledge base articles and train co-workers when required Qualifications Two or 4 years degree in and IT related fields preferred. A+ and Microsoft certifications are desirable. Demonstrates advanced working knowledge of PC hardware, printers, and networking. Knowledge and experience of the following IT systems is required: Microsoft operating systems, Microsoft Office, Citrix and other IS infrastructure. Application experience with ITSM (BMC Remedy), Epic, Kronos and Cisco VPN is preferable. Must demonstrate strong interpersonal, verbal communication and problem solving skills and the ability to prioritize and work effectively in a team environment. We take great care of careers. With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge - helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment. RegularStandard Hours Per Week: 40Schedule: Full-time (40 hours) Shift Details: Day shift 0730-1600. Occasional OT and Holidays required

Division:HEALTH AND HOSPITAL CORPORATION Sub-Division: HQ FLS Status: [[JOB_REQUISITION_CUSTOM27]] Marion County Public Health Department is an organization that celebrates diversity, and seeks to employ a diverse workforce. We actively encourage all individuals to apply for employment and to seek advancement opportunities. Marion County Public Health Department also provides reasonable accommodations to qualified individuals with disabilities as required by law. For additional questions please contact us at: *****************. Job Role Summary The position offers an intern the opportunity to gain practical experience working within a Compliance Department. They will assist with ensuring the organization adheres to all relevant healthcare laws, regulations, statutes, and ethical standards. The intern will focus on Public and Community Health Programs. Responsibilities include review of programs, workforce, and patient records, analysis of revenue cycle, identifying potential compliance risks, developing educational materials and resources for staff, and special projects ad hoc. The participating intern will be an integral part of the Compliance Department and will obtain hands on valuable experience. Potential projects for 2026 include but are not limited to the risk area of vulnerable adult populations, data integrity, and billing/claims practices. Additional areas of exposure may include The Marion County Public Health Department, Primary Care, Mobile Integrated Health, Mobile Crisis, Residential Care for Sandra Eskenazi Mental Health Center, and the CICI program. Essential Duties Intern Job Responsibilities: Program Review: Program evaluation or evaluation of key aspects of a department or specific program within the organization. Workforce: Monitoring professional licensures, criminal record position exclusions, Office of Inspector General Sanctions, and background checks; Projects associated with s, and compliance with regulations for emergency management, workplace violence initiatives, complying with position requirements, job descriptions for interns and/or students, vendors, or contractors. Data Analysis: Patient privacy, reviewing patient records and/or documentation to identify potential discrepancies and errors, billing, coding, and/or reimbursement. Compliance Audits: Internal audits related to compliance with HIPAA, Stark Law, and Anti-Kickback statutes, as well as Grant Agreements. Policy or Document Development: Contribute to the development and revision of Compliance policies, procedures, job aids, infographics, or work instructions. Training or Resource Support: Help create and deliver Compliance training and education materials for healthcare staff. Incident reporting: Compliance investigations and how to document compliance-related matters. Research: How to stay current on healthcare compliance laws, statutes, and regulations. Associated Job Duties * Other duties as assigned within the scope of training and education. Key Competencies: Competencies at the end of the internship will include documentation and a presentation of a program review or audit. The ability to display communication skills, time management, attention to detail and collaboration with internal and external department stakeholders. Demonstration of organizational values and support the mission of caring for vulnerable populations. Qualifications Education/Experience: * Student enrolled in a college or university with an interest in public health, healthcare, human resources, finance, business, corporate compliance, risk management or quality assurance. Other qualifications: * Ability to travel as needed to other clinical locations * Ability to stand or sit for long periods of time * Maintain protected health information in accordance with HIPAA privacy guidelines and applicable laws/regulations * Exercise discretion and confidentiality Knowledge, Skills & Abilities * Detail oriented * Ability to listen objectively * Excellent verbal and written communication skills * Microsoft Office experience preferred * Ability to work in a team environment as well as work independently with guidance. Working Environment * Primarily in office or remote but occasionally in patient care/clinic areas * May be required to attend meetings or perform work remote from the hospital campus * Work hours are flexible but primary during 7:30-4:30 time frame All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status. Nearest Major Market: Indianapolis

011230 CA-Provider Engagement & Performance Commonwealth Care Alliance's Long-Term Services and Supports (LTSS) team is responsible for relationship management with the contracted community-based organizations (CBOs) that provide service coordination and other supports for CCA members. This includes providing ongoing training and technical assistance on policies and procedures, interfacing with other CCA departments to promote strong working relationships between CCA staff and CBOs and the ongoing evaluation of the appropriateness, efficiency and quality of the services provided. The LTSS Program Specialist will have a wide range of responsibilities including project management support, data review, documentation, and assisting external partners. There will be opportunities to contribute beyond the essential duties and responsibilities listed below based on individual interest and demonstrated capabilities. The position will report to the LTSS Program Manager. Reporting to the Manager, LTSS Program, this position supports the efficient operations and performance of CCA's contracted CBOs by providing project management support and performing specified administrative functions, including, but not limited to: (a) invoice management, (b) member roster management, (c) coordination of onboarding and training of related CBO staff, (d) data review, reporting and analysis, and (e)assistance to these external partners as necessary. The Specialist is expected to work with managers and staff across the organization as well as interface with external community-based partners. There will be opportunities to contribute beyond the essential duties and responsibilities listed below based on individual interest and demonstrated capabilities. Supervision Exercised: - No, this position does not have direct reports. Essential Duties & Responsibilities: - Support LTSS network program operations o Developing agendas, taking, and disseminating notes, documenting action steps, communication, and follow-up with members of group with the oversight of the Manager, LTSS Program o Schedule regular check in meetings/calls with ASAPs and LTSC Agencies - Performance reporting/data management support o Link with CCA's Business Intelligence team and Provider Engagement Analytics Manager to request reports as needed o Perform data quality checks, and additional data review steps o Contribute to the development of reports to share with CBOs to provide information about their operations and performance o Continued development of specifications for reports; work with finance, business intelligence and other CCA teams to develop, implement and update existing reports o Support maintenance of reporting inventory - Roster Reporting and Reconciliation o Partner with CCA's Eligibility Team to obtain and perform data entry on information from ASAPs and LTSC Agencies related to member rosters and enrollment records o Perform data quality checks, and additional data review steps, to ensure data integrity of member record to include accurate ASAP, LTSC Agency, GSSC and LTSC, among other details o Coordinate Provider Rosters with the Provider Data Networks Team - Disseminate information to CBOs o Support Manager in developing guidelines, reference guides, workflows and SOPs, disseminating them to CBOs and answering questions to ensure efficient day to day operations o Draft email communications under supervision of Manager o Maintain materials and design of CCA Extranet/Sharepoint as a key resource for information o Ongoing communication with CBO staff and CCA internal departments through email and phone calls - Onboarding o Manage onboarding process to ensure all trainings and documentation are completed o Connect with appropriate departments across CCA to complete Onboarding process o Manage role transitions and terminations by checking in with appropriate departments across CCA and confirming termination of access to CCA accounts (Reporting, ECW, Extranet, Guiding Care, LMS, and others) o Update Staffing lists on a monthly basis and share with appropriate teams across CCA - Manage Assignment Transfer process and workflow for CBOs related to agency or GSSC and LTSC assignment transfers - Support ad hoc trainings and meetings o Prepare meeting materials, agenda creation, note-taking, and manage other meeting logistics for meeting bringing together all CBOs with key CCA staff to share best practices and lessons learned o Coordinate with CBOs to ensure staff registration and participation o Maintain training agendas, presentations, and attendance sheets o Support LTSS Program Manager in times of audits - Contribute to maintaining relationships with internal departments and partnered organizations as needed to promote the goals of LTSS Program - Track support tickets to ensure resolution - Manage tracking logs for assignment transfers, support tickets, issue escalations, extranet, and communications - Other duties as assigned Working Conditions: - This is a remote or hybrid role with the expectation of working according to Commonwealth Care Alliance's standard operating hours of 8:30am-5pm Monday-Friday. Required Education (must have): - Bachelor's degree Desired Education (nice to have): - Bachelor's degree in public health, health management, social work, or a related field preferred. Required Experience (must have): - 1+ years of experience Desired Experience (nice to have): - Experience with dual-eligible (DSNP) populations preferred. - 1+ years of experience in LTSS, social work, provider relations, healthcare communications, project management, or network management within a health plan or similar environment. Required Knowledge, Skills & Abilities (must have): - Must have ability to learn new systems and databases that CCA implements. - Working knowledge of Medicare and Medicaid (MassHealth) - Familiarity with and full support of independent living, recovery, and person-centered planning philosophy and strategies; - Must be proficient in the use of computers, specifically Microsoft Office suite. - Demonstrated skills in Excel and PowerPoint - Experience or knowledge of community based services for seniors and disabled individuals, including extensive knowledge of the ASAPs. - Polished, professional presentation skills in working with key provider partners and internal leaders. - Exceptional written and verbal communication skills, with the ability to translate complex information for diverse provider and internal audiences. - Excellent organizational, analytical, and problem-solving abilities. - Ability to build and maintain positive relationships and collaborate effectively with internal and external stakeholders. - Proactive in identifying issues and developing effective solutions. - Adaptable and able to thrive in high-pressure environments, adjust to shifting priorities, and manage multiple deadlines. - Results-oriented and self-motivated, with the ability to work independently and as part of a team to meet departmental goals. - Demonstrates empathy, self-awareness, and the ability to navigate sensitive conversations diplomatically. - Must be able to work collaboratively and create an atmosphere of trust and respect within project teams and with external partners - Must be highly organized and self-directed with a proven ability to work with supervision on departmental and cross-functional projects of a diverse nature - Requires excellent interpersonal skills in order to communicate and work with staff and external partners of all skill and experience levels - Strong tactical performer - Demonstrated ability to establish and manage performance and outcome metrics. - Ability to establish and maintain positive and effective work relationships with internal staff, external vendors, and state and federal agencies - Proven skills, knowledge base and judgment necessary for independent decision-making - Excellent organizational, time-management and problem-solving skills - Must be able to exercise a high level of diplomacy to recognize politically sensitive issues - Ability to multi-task and switch gears quickly / effectively Required Language (must have): - English Desired Knowledge, Skills, Abilities & Language (nice to have): - Familiarity with provider network management systems and healthcare data standards. - Project management skills with the demonstrated ability to handle multiple projects. - Strong understanding of Medicare, Medicaid, duals program, and health plan operations, including regulatory and compliance requirements. - Demonstrated knowledge of DMH system and waiver programs helpful. - Demonstrated ability to describe and assess a simple business problem - Demonstrated ability to define a solution to a simple business problem and develop a plan for resolution **Compensation Range/Target: $23.08 - $34.62** Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. EEO is The Law Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

082310 InstED-Medical Expenses Reporting to the CMO/Medical Director and Associate Medical Director of inst ED, the Virtual Medical Control (VMC) Physician provides medical decision making, including all elements of diagnostics, treatment, and disposition, to patients seen by inst ED's Mobile Integrated Healthcare service. The VMC serves as the clinician of record, prescribes short-term treatments, documents the encounter in inst ED's medical record, and relays any essential follow-up needs to the care team via the inst ED Clinical Resource Center (CRC) team. This is a per-diem position with a minimum commitment of four (4) shifts per month, including a mix of weekend, weekday and holiday shifts. inst ED currently operates 9a-10p ET, 365 days a year. Supervision Exercised: No, this position does not have direct reports. Essential Duties & Responsibilities: Provide patient-centered, high-quality acute care in place to individuals with complex medical needs per clinical protocols Work closely with mobile integrated healthcare clinicians (paramedics and EMTs) and other inst ED team members Participate in biannual performance reviews Participate in scheduled operational or clinical meetings, based on schedule availability, to remain up to date on programmatic and company activities and implications for clinical practice Collaborate with other VMCs, and with CRC team members as needed, primarily around managing visit volumes and clinical questions Provide clinical and operational feedback to management team to improve care delivery Collaborate with referring Care Partners and Primary Care Providers Document visit within the EMR in a complete, accurate, and timely manner. Documentation should include relevant data, medical decision making, and follow-up needs Attend required onboarding, training, and online compliance education courses Protect patient confidentiality Provide clinical care to patients via various telehealth technologies (telephonic, video, direct messaging) Maintain necessary professional licenses and credentials needed for independent practice Obtain licensure in additional states as inst ED grows Working Conditions: Ability to work day and evening shifts on weekdays, weekends and holidays Equipment/systems used and provided: Laptop computer, inst ED Now Platform, Electronic Health Record, Cell phone Standard remote work conditions Required Education (must have): Board Certification in Internal Medicine, Family Medicine, or Emergency Medicine MD/DO Current BLS Certification Required Licensing (must have): Active Board Certification in Internal Medicine, Family Medicine, or Emergency Medicine MD/DO Current licensure in Massachusetts Current DEA registration Desired Licensing (nice to have): Licensure in any of the following other states: Massachusetts, New Hampshire, Oregon, Rhode Island, Texas MA Health Enrollment (required if licensed in Massachusetts): Yes, this is required if the incumbent is licensed in Massachusetts. Required Experience (must have): Minimum of 3 years experience as an attending physician in acute care and/or inpatient medicine Experience caring for medically and socially complex patients Experience working collaboratively with a variety of professionals Experience providing non-face-to-face care, especially in telephone or virtual care Adaptability to change in systems and workflows Innovative, team-player, and expert communicator Required Knowledge, Skills & Abilities (must have): Ability to virtually/remotely assess medically complex patients Ability to provide person-centered, medically and clinically appropriate care options to patients Willingness to learn best practice in delivering home-based care Comfort with remote care delivery model and technology Comfort with shared decision making and patient-centered consideration of risk Ability to virtually/remotely assess medically complex patients Ability to work in a team-based care delivery model Strong written and verbal communication skills Comfort with Health IT and EHR systems Required Language (must have): Ability to speak/read/write English fluently Desired Knowledge, Skills, Abilities & Language (nice to have): Experience working with EMS professionals (paramedics/EMTs)

Division:Eskenazi Health Sub-Division: Hospital Schedule: Full Time Shift: Days Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 333-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus including at a network of Eskenazi Health Center sites located throughout Indianapolis. Overview of the Health Connections Team: When faced with a health care situation or looking to establish care, many people don't know where to start. Eskenazi Health Connections can help by facilitating patient/client needs such as: establishing a new patient/client well or healthcare appointments, scheduling return care appointments, and other patient/client related requests. Where Do I Fit In? Eskenazi Health Connections supports to link patients/clients who call for primary and specialty care services, including scheduling appointments, medication refill inquiries and assistance with managing acute and chronic health conditions. This requires each Connections PSA/Referral Coordinator to maintain positive customer interaction, as the coordinator answers incoming patient/client telephone calls regarding Eskenazi Health services. What Does Training Look Like? We have dedicated trainers who will assist with learning the role! We have a comprehensive training for the first 3 weeks, 8:00am-4:30pm; Mon-Fri. During this timeframe new team members will be introduced to the department, systems and policies in place, role definitions and metrics as it pertains to individual productivity. Continued support is provided by both trainers, and seasoned staff who support in the PSA/Referral Coordinators II role. Schedule: We are open 24/7, therefore we have a variety of 8-hour shifts that could be available - day shift will start at 7:30am, 8:00am, 8:30am, or 9am, a mid-shift 11:00am-7:30pm, evening shift which is 3:00pm-11:30pm and, night shift for seasoned staff from 11:00pm-7:30am. The scheduled days are either Mon-Fri or four set days during the week and every other weekend. * We also have PRN opportunities to assist with coverage for times we experience higher call volumes. There is a requirement to be available at least one weekend day, per pay period* Am I Able to Work from Home? All new team members will work on site at, 720 Eskenazi Ave. Working from home is an earned opportunity for those whom overall attendance and performance meets individual, departmental, and organizational expectations. Am I Qualified? 2 years of experience in call center, patient registration, scheduling, health information management, or other similar experience in healthcare setting required * High School diploma or equivalent required; Associate's degree is preferred * Certificate in medical terminology highly preferred I am Interested! What is the Interview Process? We will review your application in consideration of being invited to complete the first step of our interview process, a one-way video interview. Once completed, the one-way video interview is reviewed in consideration of being scheduled for a in person interview with the leadership team - to share more about the opportunity, the department/team, answer your questions, and learn more about you and your experience! Essential Functions and Responsibilities * Receives inbound and places outbound telephone triage unit patient and scheduling calls, handling a variety of calls (i.e., establishing a new patient/client well or healthcare appointments, scheduling return care appointments, and other patient/Client related requests) * Identifies the patient within the Eskenazi Health network * Adapts activities/behaviors to reflect and ensure adequate service appropriate to the age of the patient served, (i.e., neonatal, infant, pediatric, preschool, school-age, adolescent, adult, and geriatric) * Provides the highest quality of customer service to patients * Schedules appointments; enters appointment date and time * Responds and acts quickly, giving attention to detail; escalates delays in resolving patient concerns * Answers patient telephone inquiries regarding Eskenazi Health, Specialty Clinics and Ambulatory Care * Obtains and verifies medical record number for existing callers; obtains and provides number for new callers; refers all inquiries to the appropriate areas of services * Documents all inquiries for medical, legal, and statistical purposes * Informs Connections nurse of callers with emergent symptoms for triage and serves as clinic liaison to assigned clinics * Informs patient and/or family of the patient obligation policy, directing patient to financial counselors when patient has no coverage for ordered procedure or visits Knowledge, Skills, and Abilities * Demonstrates a positive demeanor, exemplary customer service skills, and excellent oral and written communication skills, including age/education appropriate communications * Possesses basic mathematical and analytical skills to resolve referral issues as they relate to physician schedules, patient care needs, and organizational standards * Ability to establish priorities, multitask, meet deadlines, and follow written and verbal instructions * Competency in use of standard office equipment, Windows, Word, Chrome, and Excel Accredited by The Joint Commission and named as one of Indiana's best employers by Forbes magazine for two consecutive years and the top hospital in the state for community benefit by the Lown Institute, Eskenazi Health's programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city's primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the only verified adult burn center in Indiana and Sandra Eskenazi Mental Health Center, the first community mental health center in Indiana, just to name a few. Nearest Major Market: Indianapolis

Coast Medical Service is a nationwide travel nursing & allied healthcare staffing agency dedicated to providing an elite traveler experience for the experienced or first-time traveler. Coast is featured on Blue Pipes' 2023 Best Travel Agencies and named a 2022 Top Rated Healthcare Staffing Firm & 2023 First Half Top Rated Healthcare Staffing Firm by Great Recruiters. Please note that pay rate may differ for locally based candidates. Please apply here or contact a recruiter directly to learn more about this position & the facility, and/or explore others that may be of interest to you. We look forward to speaking with you!

011250 CCA-Claims Hiring for One Year Term This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this time. Working under the direction of the Sr. Director, TPA Management and Claims Compliance, Healthcare Medical Claims Coding Sr. Analyst will be responsible for developing prospective claims auditing and clinical coding and reimbursement edits and necessary coding configuration requirements for Optum CES and Zelis edits. This role will ensure that the applicable edits are compliant with applicable Medicare and Massachusetts Medicaid regulations. The role will also be responsible for timely review and research, as necessary on all new and revised coding logic, related Medicare/Medicaid policies for review/approval through the Payment Integrity governance process. Supervision Exercised: No, this position does not have direct reports. Essential Duties & Responsibilities: Develop enhanced, customized prospective claims auditing and clinical coding and reimbursement policies and necessary coding configuration requirements for Optum CES and Zelis edits. Quarterly and Annual review and research, as necessary on all new CPT and HCPCS codes for coding logic, related Medicare/Medicaid policies to make recommend reimbursement determinations. Analyze, measure, manage, and report outcome results on edits implemented. Utilize data to examine large claims data sets to provide analysis and reports on existing provider billing patterns as compared to industry standard coding regulations, and make recommendations based on new/revised coding edits for presentation to Payment Integrity committee meetings. Analyze, measure, manage, and report outcome results on edits implemented. Use and maintain the rules and policies specific to CES and Zelis. Query and analyze claims to address any negative editing impacts and create new opportunities for savings based on provider billing trends Liaison between business partners and vendors; bringing and interpreting business requests, providing solutioning options and documentation, developing new policies based on State and Federal requirements, host meetings, and managing projects to completion Define business requests received, narrow the scope of the request based on business needs and requirements, provider resolution option based on financial ability and forecasting for small to large Operations Management Collaborate system and data configuration into CES (Claims Editing System) with BPaaS vendor and other PI partners, perform user acceptance testing, and analyze post production reports for issues Support collaboration between PI/Claims and other internal stakeholders related to the identification and implementation of cost-savings initiatives specific to edits. Working Conditions: Standard office conditions. Remote opportunity. Other: Standard office equipment None/stationary Required Education (must have): Bachelor's Degree or Equivalent experience Ideal Candidate to have the one or all of the required certification OR willing to get certified within 1 year of employment - Certified Professional Coder (CPC) Certified Inpatient Coder (CIC) Certified Professional Medical Auditor (CPMA) Desired Education (nice to have): Masters Degree Required Experience (must have): 7+ years of Healthcare experience, specific to Medicare and Medicaid 7+ years progressive experience in medical claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required 7+ years experience with Optum Claims Editing System (CES), Zelis, Lyric or other editing tools Extensive knowledge and experience in Healthcare Revenue Integrity, Payment Integrity, and Analytics 5+ years of Facets Claims Processing System Required Knowledge, Skills & Abilities (must have): Knowledge and experience of claim operations, health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare) Medical Coding, Compliance, Payment Integrity and Analytics Direct and relevant experience with HCFA/UB-04 claims management, coding rules and guidelines, and evaluating/analyzing claim outcome results for accurate industry standard coding logic and policies (i.e . Center for Medicare & Medicaid Services (CMS) & MA Medicaid, Correct Coding Initiative (CCI), Medically Unlikely Edits (MUEs) both practitioner and facility, modifier to procedure validation, and other CMS and American Medical Association (AMA) guidelines, etc.) Advanced experience of medical terminology and medical coding (CPT, HCPCS, Modifiers) along with the application of Medicare/Massachusetts Medicaid claims' processing policies, coding principals and payment methodologies Ability to work cross functionally to set priorities, build partnerships, meet internal customer needs, and obtain support for department initiatives Ability to plan, organize, and manage own work; set priorities and measure performance against established benchmarks Ability to communicate and work effectively at multiple levels within the company Customer service orientation; positive outlook, self-motivated and able to motivate others Strong work ethic; able to solve problems and overcome challenges Required Language (must have): English Compensation Range/Target: $64,000 - $96,000 Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

011230 CA-Provider Engagement & Performance The HEDIS Network Analyst will support CCA's ability to meet and surpass critical Quality benchmarks and optimize member outcomes as measured through critical measures. The role supports efforts of the organization's Network and Provider Contracting department and will have regular interaction with relevant internal Clinical, Quality, and BI departments, while frequently interfacing with Providers within CCA's Network. The objective of this role is to reduce and or prevent loss of revenue due to below-benchmark performance on critical Quality measures. Priority measures may shift year-to-year as dictated by organizational performance trends and the Network's ability to impact these trends. This role's three key areas of focus will be to: 1. Identify underperforming Providers 2. Work cross-functionally to determine reasonable expectations and solutions 3. Facilitate and implement Provider specific and/or Network improvement initiatives Current year priority measures include Initiation and Engagement of Alcohol or Other Dependence Treatment (IET) and Follow-Up after Hospitalization for Mental Illness (FUH) The ideal candidate will have strong organizing skills, analytic capabilities, and the ability and comfort with working across internal and external stakeholders to coordinate initiatives and projects affiliated with Quality performance improvement. Supervision Exercised: No, this position does not have direct reports. Essential Duties & Responsibilities: Conduct weekly tracking of Quality/ HEDIS metrics, specifically focused on Initiation and Engagement of Alcohol or Other Dependence Treatment (IET) and Follow-Up after Hospitalization for Mental Illness (FUH) data: Work with BI, Quality, and BH teams to evaluate and build data sources delivering accurate performance data and reliable actionable data Track performance trends on a weekly basis, evaluating member-specific and provider level details Identify reasons for low and high performance; which providers are doing well and which are struggling? Which diagnosis setting is leading to the highest number of missed opportunities for a timely Initiation visit? Identify which Network providers are excelling and which are underperforming. Design IET and FUH data formats that are user-friendly and can be shared with relevant Network Providers, including those with delegated arrangements Review YTD claims files on a monthly/quarterly basis to identify errors and address accordingly with appropriate SMEs Meet with select Providers and HHs to discuss IET and FUH performance and workshop improvement interventions with short term and long-term goals Understand barriers and challenges providers are experiencing Work with high performers to build a comprehensive list of tips and best practices that can be shared with lower performing entities and with CCA's internal BH and Care Partnership teams Determine regular cadence to check-in with lower performing HHs and Providers to get updates on their progress Partner with CCA Clinical teams and programs to build a roll out initiatives aimed at leveraging Providers to improve Quality measures Train and Education Provider Network on the measures Organize trainings, working with Quality and Clinical teams to build reference documents and aggregate content for webinars; work with appropriate SMEs to ensure materials and trainings are modified for different Provider audiences Working Conditions: This is a remote role with the expectation of working according to Commonwealth Care Alliance's standard operating hours of 8:30am-5pm Monday-Friday. Member Facing: ☒ NO: The job duties do not involve face-to-face contact with members, even for staffing coverage purposes. Required Education (must have): Bachelor's degree or equivalent experience within healthcare project management, HEDIS and STARs measures, population health, and the health plan space Desired Education (nice to have): Master's degree within healthcare management and administration, public health, business administration or relevant field MA Health Enrollment (required if licensed in Massachusetts): No, this is not required for the job. Required Experience (must have): 5+ years of experience working within community-based health and/or managed care Desired Experience (nice to have): Experience working within community-based health and/or health plan organization to lead Network projects, clinical implementation, and/or population health initiatives Required Knowledge, Skills & Abilities (must have): Strong organizing skills and analytic capabilities Demonstrated understanding of the duals programs and Network quality measures Analytic mindset with the ability to work within larger data sets to identify trends and produce actionable recommendations Proven experience and understanding of HEDIS and Health Plan quality initiatives; familiarity with behavioral health KPIs such as IET and FUH Results oriented and self-motivated with the ability to work independently and collaboratively across internal and external stakeholders Has the ability to thrive in high pressured environments, adjust to shifting priorities, and multi-task Working knowledge of project/program management practices Strong verbal communication skills with the ability to present data insights to various audiences, facilitate meetings and project plans Proficiency with spreadsheets and databases, including excel, PowerPoint, and word Team player with interest and ability to pivot as needed to meet the larger performance goals of the Network departments Required Language (must have): English Compensation Range/Target: $54,800 - $82,200 Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

011110 CCA-Public Affairs The Director of State Government Affairs (“Director”) sits within The Government Affairs team and reports to the Vice President of Government Affairs/CareSource. This position also supports the CCA Plan President. In collaboration with the VP, Government Affairs, department leadership and relevant market and corporate development leadership, the Director is responsible for the establishment and execution of the state policy, advocacy strategy & community engagement in Massachusetts. The Director is responsible for coordinating policy positioning and advocacy strategy, collaborating with marketing and public relations on CCA's market positioning and executing on the Massachusetts Government Affairs plan to advance CCA's goals at the state level to defeat or mitigate actions by state officials that could negatively affect CCA's business or the consumers we serve. The Director is responsible for tracking legislative, regulatory and administrative activity, modifying and updating the Government affairs plan accordingly and proactively communicating to public affairs leadership, market leadership and affected business units any changes in law or policy that impact CCA's business. The Director serves as the primary point of contact with trade associations engaged in state advocacy and supports alliance development with key stakeholders. The Director is responsible for intimately understanding and continuously enhancing strong relationships with the wide range of advocacy organizations across Massachusetts who are focused on the needs of individuals served by CCA, including those with disabilities and other complex health and social needs. He/she/they will also be primarily responsible for the creation and submission of CCA' community benefit report to the office of the Massachusetts Attorney General. This is an individual contributor role in the organization with a high degree of impact with both internal and external stakeholders. Supervision Exercised: No, this position does not have direct reports. Massachusetts Market Contract Key Personnel: No, this position is not identified in the contract/s as key personnel. Essential Duties & Responsibilities: Monitor and analyze legislation and regulatory activity in Massachusetts and communicate changes and implications to the relevant corporate partners to mitigate risk for departments across the organization. Proactively identify and communicate policy and political issues and trends that impact the company to relevant internal key stakeholders. Collaborate with appropriate CCA departments to develop state policy positions that advance CCA's business interests: Develop subject matter expertise on a wide range of relevant state policy issues and provide insightful analysis on those issues with internal business partners. Lead development of policy resources and materials to achieve state market policy goals. Collaborate with other members of the legal and public affairs departments to prepare internal and external facing materials (white papers, testimony, articles, press releases, speeches, presentations, messages to the Board, letters-to-editors, op-eds, etc.) to promote CCA's policy positions. Ensure alignment between state specific policy positions and CCA federal policy positions. Maintain and deepen strategic relationships with state elected officials, staff, and agencies. Support the corporate compliance department to interpret and implement applicable provisions of legislation and regulations in Massachusetts. Establish and maintain an intelligence-gathering strategy to proactively identify emerging trends to help the company navigate business decisions. Advise company leadership on state political activity. Manage a network of business and trade association partners in the region: Attend industry events to manage and nourish relationships with trade associations. Maintain communication channels with trade associations to gather intelligence on industry priorities and legislative and political developments relevant to those priorities and to provide feedback on proposed legislation, regulations, and similar guidance. Work closely with like-minded advocacy organizations and serve as a representative on coalitions to further common policy priorities. Collaborate with the Vice President, Government Affairs in the identification, selection, contracting and oversight of state lobbyists and other consultants. Ensure that CCA is viewed as aligned with and supportive of the advocacy community's goals, including overseeing CCA's community sponsorship program, with the goal of fostering good will and strong advocacy community support of CCA. Work collaboratively with the Vice president of Government Affairs, and with internal stakeholders, identify the target populations, organizations and initiatives in which CCA will invest its charitable resources Work collaboratively with the Vice President, market, and corporate development leadership to establish annual goals and clear metrics to support progress toward those goals. Is responsible for monitoring, tracking, and reporting on the performance of CCA's retained lobbyists and consultants against those metrics. Other tasks as assigned. Working Conditions: Standard office conditions. In-state travel required. Must reside in Massachusetts and be in the office multiple days a week. Member Facing: ☐ YES: The job has in-person contact (not telephonic/virtual) with CCA members or patients as part of the job duties. ☐ PARTIAL: The job is expected to have in-person contact with CCA members or patients on a very limited capacity, only as part of a supervisory role or in a staffing crisis. ☒ NO: The job duties do not involve face-to-face contact with members, even for staffing coverage purposes. Required Education (must have): Bachelor's Degree in relevant field required Desired Education (nice to have): Master's Degree preferred. MA Health Enrollment (required if licensed in Massachusetts): No, this is not required for the job. Required Experience (must have): 3-5 years related work state legislative, government advocacy or health care policy. A minimum of three (3) years of experience with Medicaid & Medicare managed care and other public health care programs is required. Experience developing written materials for internal and external audiences. Experience attending to variable legislative issues while meeting time-sensitive deadlines. Experience in effectively communicating complex ideas to company executive leadership, top-level government leaders and external thought leaders to win support for the company. Desired Experience (nice to have): 2-4 years' experience as a registered lobbyist/advocate. Public Speaking Charitable giving experience Required Knowledge, Skills & Abilities (must have): Strong passion for and interest in Medicare/Medicaid, disability and social policy and advocacy on behalf of CCA's membership. Knowledge of inner workings of the Massachusetts state government, policymaking, and budgetary processes. Excellent collaboration, problem-solving and organizing skills. Persuasive writing skills Required Language (must have): English Other (optional): Standard office equipment Compensation Range/Target: $133,600 - $200,400 Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Coast Medical Service is a nationwide travel nursing & allied healthcare staffing agency dedicated to providing an elite traveler experience for the experienced or first-time traveler. Coast is featured on Blue Pipes' 2023 Best Travel Agencies and named a 2022 Top Rated Healthcare Staffing Firm & 2023 First Half Top Rated Healthcare Staffing Firm by Great Recruiters. Please note that pay rate may differ for locally based candidates. Please apply here or contact a recruiter directly to learn more about this position & the facility, and/or explore others that may be of interest to you. We look forward to speaking with you!

025010 Clin Alli-CCAPC CCA Primary Care provides primary care for complex patients with disabilities and frail elders in their home, virtually, or at one of our clinic locations. We are an interdisciplinary care team consisting of APCs, physicians, behavioral health clinicians, nurses, medical assistants, rehab, and administrative staff. The Clinical Support Coordinator provides day to day administrative support to the care team including but not limited to coordinating outgoing referrals to specialists and VNA agencies, scheduling patient appointments, scanning and filing documents, front desk support, sending correspondence, answering phone calls and any other administrative tasks needed as determined by the care team to ensure patients receive timely and high-quality care. Supervision Exercised: No Essential Duties & Responsibilities Intake calls from members, families, caregivers, providers, facilities, and agencies, accurately documenting in the medical record and routing appropriately. Coordinate outgoing referrals to VNA agencies and specialists by ensuring external facilities receive required paperwork in a timely manner, follow-up to ensure acceptance and assist with scheduling appointments for our patients when needed. Schedule appointments for patients including coordinating new patient visits, annual physicals, and hospital discharge follow-ups following practice protocols and/or expectations. Provide front desk support when scheduled, including but not limited to checking patients in and out for their visits, completing insurance eligibility checks, and contacting transportation when needed. Draft correspondence as requested by care team such as Jury Duty letters, Utility shutoff protection letters, and Letters of Medical Necessity. Obtain medical records or discharge summaries for patients as needed from outside facilities. Monitor incoming faxes and save documents appropriately in the medical record, routing appropriately for review/signature/completion based on the type of document. Complete reminder calls for upcoming visits. Fax documents and/or prescription orders to pharmacies at request of clinicians. Conduct test calls via telehealth technologies (video, chat) to ensure patients are able to connect successfully for telehealth appointments. Working Conditions Standard office conditions. Required Education High School Diploma/GED Desired Education Associates degree Required Experience 1-2 years related experience either in a healthcare or medical office setting Required Knowledge, Skills & Abilities Ability to prioritize workload and manage multiple projects simultaneously Microsoft Office (Outlook, Excel, Word, PowerPoint, Teams) Ability to problem solve with minimal supervision. Excellent written and verbal communication skills. Excellent organizational skills. Knowledge of medical terminology. Able and willing to embrace change to support process improvement initiatives. Must be a Team player Experience in working with Electronic Medical Records (EMRs) Required Language(s) English Desired Language(s) Bilingual in Spanish preferred Bilingual in Hattian Creole, Brazilian Portuguese, Portuguese, or any other commonly spoken language Compensation Range/Target: $21.61 - $32.42 Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

011230 CA-Provider Engagement & Performance The Senior Provider Relations Specialist is responsible for building, maintaining and strengthening relationships with the Commonwealth Care Alliance's (CCA) diverse provider community - including physician, hospital, behavioral health, community-based, LTSS, and HCBS providers. This individual serves as a key liaison, proactively addressing provider needs, ensuring regulatory compliance, and supporting operational excellence to enhance provider satisfaction and member access to care. Reporting to the Senior , Director of Delegation Partnerships., the Senior Provider Relations Account Manager will: + Lead provider servicing activities, including onboarding, orientation presentations, and ongoing education initiatives. + Serve as a primary resource for resolving provider inquiries and supporting issue resolution. + Collaborate in the implementation of CCA's enterprise-wide provider engagement strategy, focused on delivering a best-in-class provider experience. + Utilize strategic planning and data-driven insights to identify opportunities for continuous improvement in provider relations and organizational performance. By fostering strong partnerships and supporting process enhancements, the Senior Provider Relations Account Manager plays a vital role in helping CCA achieve its mission and goals within the provider community. **Supervision Exercised:** + No, this position does not have direct reports. **Essential Duties & Responsibilities:** + **Relationship Management** + Develop strong professional relationships with providers across all specialties -, physician, hospital, behavioral health, community based, and ancillary providers and their staff. + Serve as the primary liaison to the provider community, researching, resolving, and escalating complex provider issues as needed. + Own provider relationships to drive satisfaction, retention, and operational efficiency. + **Provider Education and Support:** + Facilitate and lead communication sessions, educating on CCA's policies, program benefits, billing, referral and authorizations regulatory compliance, and contractual expectations. Conduct orientation and ongoing education (virtual and in-person) for new and existing providers. + Identify and address training needs, collaborating with internal education and training teams to develop materials. + **Operational Excellence:** + Collaborate with cross-functional teams (e.g., Claims, Credentialing, Clinical Care Management, Member Services, Provider Services, Regulatory Affairs, Marketing) to resolve provider issues and reduce administrative burden. + Conduct site visits when necessary and coordinate with credentialing department to ensure the collection of required applications and other credentialing documentation + Manage and respond to a high volume of provider inquiries while ensuring consistent follow through on resolution of issues + Prioritize and organize own work to meet deadlines + Work collaboratively with Provider Network Management staff to ensure an adequate and appropriate provider network When necessary, participate in contracting strategy discussions around potential recruitment opportunities + Coordinate with other CCA departments, including Clinical Management, Member Services, Claims, Regulatory Affairs, Outreach and Marketing, to resolve provider issues. Attend and participate in department staff meetings + Assists in the development of training materials and training of Provider Relations Specialists. + Assist with designated provider communication tasks. + Special projects as assigned or directed **Working Conditions:** + Standard office conditions. + This is a remote or hybrid role with the expectation of working according to Commonwealth Care Alliance's standard operating hours of 8:30am-5pm Monday-Friday. **Required Education (must have):** + Bachelor's Degree or equivalent experience **Desired Education (nice to have):** **Required Licensing (must have):** **Desired Licensing (nice to have):** **MA Health Enrollment** **(required if licensed in Massachusetts):** + No, this is not required for the job. **Required Experience (must have):** + 5+ years of experience **Desired Experience (nice to have):** + Experience with dual-eligible (DSNP) populations preferred. **Required Knowledge, Skills & Abilities (must have):** + Strong claims experience + Mentoring subject matter expert of the team + Managed Care experience (preferably Medicare/Medicaid) + Experience in health plan provider relations + Experience with behavioral health providers preferred + Understanding of provider office operations as they relate to health plans + Knowledge of billing practices and reimbursement methodologies + Excellent verbal, written and presentation skills + Outstanding Customer Service Skills + Intermediate Microsoft Office competency, including Outlook, Word, Excel & Power Point + Ability to interact well with individuals on all levels, and maintain a professional image and attitude + Strong analytical, problem solving, and project management skills + Detail oriented, with the ability to organize and manage multiple priorities Valid Driver's license and reliable insured automobile required **Required Language (must have):** + English **Desired Knowledge, Skills, Abilities & Language (nice to have):** **Compensation Range/Target: $85,200 - $127,800** Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. EEO is The Law Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

023430 Clin Alli-Clin Assessment & CP Commonwealth Care Alliance's (CCA) Assessment unit conducts initial and ongoing face-to-face assessments for CCA enrollees. The Unit is also responsible for evaluating the accuracy and quality of all assessments and ensuring timely submission to MassHealth. The department includes registered nurse assessors and reviewers. The assessors are organized into teams and geographically dispersed across the commonwealth The Assessment nurse conducts timely, high-quality, accurate in-person assessments. These individuals leverage the Minimum Data Set (MDS), Comprehensive, and Functional Assessment using data collected during the assessment process to identify the member's concerns and unmet needs. This individual works collaboratively with other members of the care team and staff in other departments as needed to support timely interventions designed to improve outcomes for CCA members. The Assessment nurse reports to the Regional RN Supervisor. Supervision Exercised: No, this position does not have direct reports. Essential Duties & Responsibilities: Conducts in-person assessment visits and clinical exams, if appropriate, and relevant screenings within assigned territory as scheduled to capture members' clinical needs and meet regulatory requirements. Medication reconciliation, adherence concerns, vital signs, and acute and chronic disease education. Complete additional tools or screeners as needed, including relevant behavioral health screeners (PHQ-9, EASI, Audit, DAST). Uses clinical judgment to escalate members with urgent needs to the Regional RN Supervisor and/or manager during or immediately following the visit. Utilize our electronic health record, scheduling platforms, and claims platforms to collect data, document member interactions, organize information, and communicate with your team, members, and care team. Understanding of how to use electronic health record systems and /or care management platforms to ensure accurate documentation. Willing and able to pivot to various tasks as needed to support the needs of the department best. Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities. Ensures immediate referral to time-sensitive services such as behavioral health, long-term services, and support. Manages assessment activities through the calendar and tracks the status of completion. Participates in assessing and improving quality within the scope of responsibilities and throughout the organization. Participates in activities and education to maintain and advance clinical competencies Seeks to maintain a constructive work environment and maintains effective communication with other employees and managers. Maintains confidentiality of patient and employee information. Compliance with the organization's policies and procedures. Provide clinical assessments to members via telehealth technologies (video, chat, etc.) when clinically appropriate. Use the data collected during the assessment to identify member concerns and unmet needs so that the care team can develop and formalize an individualized care plan. Collaborate with care team members to determine whether members need to be placed in a different program (for example, lower or high-intensity programs). Working Conditions: Work locations include residential and community sites. Must be willing and able to travel to member's homes and work remotely occasionally. Valid driver's license with no restrictions. Ability to be active and mobile across Massachusetts Member Facing: ☒ YES: The job has in-person contact (not telephonic/virtual) with CCA members or patients as part of the job duties. Required Education (must have): Associate degree in Nursing RN with an active registered nursing license in the Commonwealth of Massachusetts, in good standing. Desired Education (nice to have): Bachelor's Degree in Nursing Required Licensing (must have): RN with an active registered nursing license in the Commonwealth of Massachusetts, in good standing. MA Health Enrollment (required if licensed in Massachusetts): No, this is not required for the job. Required Experience (must have): 1+ years of clinical experience including clinical rotation Desired Experience (nice to have): Experience with electronic medical records strongly preferred Care Management experience Required Knowledge, Skills & Abilities (must have): Proven skills and knowledge base necessary for conducting clinical assessments, clinical decision-making and care delivery. Ability to function independently. Excellent organizational skills. Ability to function effectively as part of a team. Effective oral and written skills Strong Interpersonal and customer relation skills. Effective teaching skills. Intermediate to Advanced understanding of Microsoft Office Suite. Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services. Required Language (must have): English Required Desired Knowledge, Skills, Abilities & Language (nice to have): Bilingual in English and second language Compensation Range/Target: $50 / hour plus $150 per Assessment completed Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

011230 CA-Provider Engagement & Performance The Behavioral Health (BH) Provider Engagement Program Manager is responsible for cultivating strong, collaborative relationships with behavioral health providers and driving performance improvement through data insights, education, and partnership. This individual will serve as the primary point of contact for BH providers, promoting alignment with CCA's mission and supporting high-quality, coordinated care for members. In this role, the Program Manager acts as an account manager, relationship manager, and performance partner - using data, provider feedback, and system collaboration to enhance provider engagement, improve outcomes, and strengthen community-based partnerships. This position works closely with CCA's Behavioral Health, Health Home, Network, and Clinical teams to ensure a seamless provider experience and consistent delivery of quality care. The BH Provider Engagement Program Manager reports to the Director of Delegation Partnerships and Provider Engagement. Supervision Exercised: • No, this position does not have direct reports. Essential Duties & Responsibilities: Provider Relationship Management • Serve as the primary relationship manager and point of contact for assigned BH providers, fostering collaboration and problem-solving. • Represent CCA's behavioral health priorities, programs, and initiatives to the provider network. • Promote provider understanding of CCA's mission, value-based approach, and expectations for quality, utilization, and member experience. • Address provider inquiries related to care coordination, utilization management, and program participation, collaborating with internal teams as needed. Performance and Data Insight • Analyze and interpret provider data related to utilization, cost, quality, and outcomes to identify performance trends and opportunities for improvement. • Develop and share actionable performance reports with providers to support data-driven quality improvement. • Collaborate with internal analytics and clinical teams to ensure data insights are accurate, meaningful, and aligned with organizational priorities. • Track provider progress on performance metrics (e.g., HEDIS, readmissions, community tenure) and follow up to support improvement efforts. Program and Partnership Support • Partner with the Health Home and Clinical teams to support consistency and quality across BH and Health Home providers. • Participate in case review meetings and rounds as needed to enhance coordination and care transitions. • Support the identification and implementation of innovative provider initiatives, pilots, and clinical improvement projects. • Build linkages between levels of behavioral health care - from inpatient to community-based - to improve transitions and continuity of care. Collaboration and Internal Coordination • Work closely with the Network and Business Development teams to ensure information and insights are shared bidirectionally. • Collaborate with cross-functional leaders, including community organizations, PCPs, and social service agencies, to strengthen relationships and community integration. • Partner with the Behavioral Health leadership team to support initiatives related to value-based payment (VBP), quality improvement, and provider engagement. Results and Accountability • Manage assigned provider relationships and related projects to meet defined goals for engagement, quality, and performance. • Develop and execute annual provider engagement plans informed by provider data, feedback, and CCA priorities. • Follow through on performance improvement activities, monitoring impact and adjusting approach as needed. Other Duties • Support departmental projects and initiatives as assigned. • Represent the Behavioral Health team in cross-functional meetings and external stakeholder discussions. Working Conditions: • This is a remote or hyrbrid role with the expectation of working according to Commonwealth Care Alliance's standard operating hours of 8:30am-5pm Monday-Friday. Ability to travel to provider offices and access to reliable transportation. Required Education (must have): • Master's degree in a behavioral health discipline (Psychology, Social Work, Counseling, or related field) or equivalent experience required. Required Experience (must have): • 5+ years • Experience with Medicaid and Medicare products and programs • Experience or knowledge of behavioral health services available to support dual eligible populations • Experience in behavioral health clinical practice, provider relations, or healthcare management Desired Experience (nice to have): • Experience working with managed care organizations, value-based programs, or community-based behavioral health providers strongly preferred • Experience with dual-eligible (SCO or One Care) populations preferred. • Experience in healthcare program management, provider relations, or network management • Knowledge of Massachusetts BH landscape Required Knowledge, Skills & Abilities (must have): • Strong relationship management and communication skills, with the ability to engage and influence diverse stakeholders. • Demonstrated analytical ability to interpret and apply provider performance data. • In-depth understanding of behavioral health systems, care delivery, and care coordination processes. • Excellent organizational, time management, and project management skills. • Ability to work collaboratively in a matrixed environment. • Proficiency in Microsoft Office Suite; experience with data reporting tools preferred. • Ability to function independently and effectively as part of an interdisciplinary team • Strong and effective communication skills, both written and verbal • Strong interpersonal and customer relations skills • Effective teaching skills • Mediation/facilitation/conflict resolution skills • Demonstrates analytical skills necessary to review data Required Language (must have): • English Desired Knowledge, Skills, Abilities & Language (nice to have): • Proven skills, knowledge base, and judgment necessary for independent clinical decision making in alignment with clinical licensure. • Strong understanding of Medicare, Medicaid (MassHealth), and dual-eligible program operations, including regulatory and compliance requirements. • Demonstrated ability to describe and assess a simple business problem • Demonstrated ability to define a solution to a simple business problem and develop a plan for resolution Compensation Range/Target: $99,600 - $149,400 Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

011230 CA-Provider Engagement & Performance The Director of Provider Relations leads the strategic vision and operational execution of provider relations for Commonwealth Care Alliance's SCO and One Care lines of business. This role is responsible for cultivating high-impact relationships with key healthcare providers, optimizing network performance, and ensuring compliance with regulatory standards. The Director drives initiatives that enhance operational engagement, member access, provider satisfaction, and value-based care outcomes, while serving as the primary liaison for escalated provider matters. This position partners closely with provider engagement, delegation partnerships, provider services, contracting, quality, compliance, medical management, and analytics teams to advance provider network operations, education, and performance improvement. The Provider Relations Director reports to the Sr Director of Delegation Partnerships and Provider Engagement. Supervision Exercised: * Yes, this position does have direct reports including Provider Relations Account Managers. Essential Duties & Responsibilities: Provider Relationship Management * Develop and execute the organization's provider relations strategy, ensuring strong, collaborative partnerships with hospitals, physician groups, LTSS, HCBS, behavioral health, and ancillary providers. * Serve as the primary point of contact for high-priority provider groups, resolving escalated and complex issues with a focus on long-term satisfaction and retention. * Lead ongoing communication efforts, working closely with Provider Communications Manager, to keep providers informed of organizational objectives, regulatory updates, operational changes, and compliance requirements. * Establish and oversee a structured process for tracking, escalating, and resolving provider issues in coordination with network, operational, clinical, and compliance teams. Network Performance & Compliance * Collaborate with contracting, operations, and analytics teams to monitor network performance against internal and regulatory benchmarks. * Ensure provider network compliance with CMS, state Medicaid agency, and NCQA standards. * Lead initiatives to streamline provider operations, reduce administrative burden, and improve the overall provider experience. * Analyze trends in provider inquiries and grievances to identify root causes, recommend process improvements, and enhance provider satisfaction and performance. * Partner with senior leaders to communicate resolution and outcomes and drive cross-functional accountability for systemic improvements. * Ensure all issue resolution processes align with regulatory requirements and organizational standards for service quality and responsiveness. Provider education * Collaborate with Provider Communications, Provider Engagement and Delegation in the development and execution of a comprehensive provider education strategy. * Oversee the design and delivery of high-impact training programs, webinars, and materials that strengthen provider understanding of CCA's model of care, operations, and compliance standards. * Partner with internal stakeholders to ensure educational initiatives support system-wide consistency and continuous improvement. * Leverage data and provider feedback to identify educational needs, measure effectiveness, and adapt programs for maximum impact. * Represent CCA as a thought leader in provider education at meetings, forums, and partnerships. * Ensure provider education efforts foster collaboration, shared accountability, and a culture of partnership across the network. Value-Based Program Support * Support Provider Engagement and Delegation Partnerships in the implementation and performance monitoring of value-based arrangements, including shared savings, risk-sharing, and quality incentive programs. * Partner with provider engagement, delegation partnerships, clinical and population health teams to drive provider engagement in quality improvement and care coordination initiatives. Team Leadership & Development * Manage, mentor, and develop a team of provider relations account managers and representatives, setting clear goals and performance metrics aligned with organizational priorities. * Foster a culture of continuous improvement, professional development, and high performance within the provider relations team. Cross-Functional Collaboration * Work closely with network contracting, credentialing, claims, IT, customer service, compliance, and quality teams to address provider needs and improve service delivery. * Lead or support provider advisory councils and feedback mechanisms to integrate provider perspectives into strategic planning. * Lead provider operations joint operating committee to ensure provider escalations and operational issues are addressed timely and effectively. * Represent Provider Network in collaborative forums and committees, including payment policy and medical policy. Other Duties * Develop and maintain SOPs related to provider mailings, education and escalations support. * Support departmental projects and initiatives as assigned. * Represent the Provider Relations teams in cross-functional meetings and external stakeholder discussions. Working Conditions: * This is a remote or hyrbrid role with the expectation of working according to Commonwealth Care Alliance's standard operating hours of 8:30am-5pm Monday-Friday. Ability to travel to provider offices and access to reliable transportation. Required Education (must have): * Bachelor's degree in healthcare administration, business administration, public health, or a related field required. Desired Education (nice to have): * Master's degree in healthcare administration, business administration, public health, or a related field required. Required Experience (must have): * 8-10 years of progressively responsible experience in provider relations, network management, or healthcare operations within a managed care organization, health plan, or integrated delivery system. * Demonstrated success building and managing provider partnerships across multiple provider types (e.g., primary care, specialty, behavioral health, hospitals, and community-based organizations). * Proven ability to analyze provider performance metrics, identify improvement opportunities, and drive accountability to outcomes. * Experience resolving escalated provider issues, collaborating cross-functionally to address root causes, and improving overall provider satisfaction. * Track record of leading provider education and engagement initiatives, including provider communications, trainings, and forums. * Demonstrated leadership and team management experience, with the ability to develop staff and lead through influence across departments. Desired Experience (nice to have): * Experience with dual-eligible (DSNP) populations preferred. * 10+ years of experience in provider relations, contracting, or network operations, including 3-5 years in a director or senior management role. * Experience with value-based payment models, performance-based contracting, or population health initiatives. * Prior work with hospital systems, large medical groups, and specialty care networks. * Experience supporting provider data integrity, onboarding, and credentialing processes. * Proven success in network development or market expansion initiatives. Required Knowledge, Skills & Abilities (must have): * Strong understanding of claims processing, reimbursement methodologies, and payment policies, with the ability to interpret and communicate their impact on provider operations and satisfaction. * Strong understanding of Medicare and Medicaid health plan operations, including regulatory and compliance requirements. * Demonstrated analytical and data interpretation skills, with the ability to translate performance data into actionable strategies. * Excellent communication and relationship management skills, with the ability to influence diverse internal and external stakeholders. * Skilled in conflict resolution and issue escalation management, maintaining professionalism and diplomacy under pressure. * Exceptional organizational, problem-solving, and project management abilities with a focus on results and accountability. * Proficiency in Microsoft Office Suite (Excel, PowerPoint, Word) and comfort with data dashboards or reporting tools. * Ability to lead and facilitate provider meetings, deliver presentations to executive audiences, and represent the organization at external events. * Strong collaboration skills and the ability to work effectively across clinical, operational, contracting, and quality teams. * Demonstrated professional presence and strategic thinking in a matrixed environment. * Ability to manage multiple priorities, adapt to changing business needs, and maintain attention to detail in a fast-paced setting. * Proactive in identifying issues and developing effective solutions. * Adaptable and able to thrive in high-pressure environments, adjust to shifting priorities, and manage multiple deadlines. * Results-oriented and self-motivated, with the ability to work independently and as part of a team to meet departmental goals. * Demonstrates empathy, self-awareness, and the ability to navigate sensitive conversations diplomatically. Required Language (must have): * English Desired Knowledge, Skills, Abilities & Language (nice to have): * Experience developing and executing provider engagement strategies aligned with network performance goals. * Familiarity with CRM systems (e.g., Salesforce) and provider relationship management tools. * Understanding of claims operations, utilization management, and quality programs as they relate to provider satisfaction and network performance. * Experience with change management and process improvement methodologies. * Knowledge of healthcare economics, reimbursement structures, and financial performance metrics. * Demonstrated commitment to equity, inclusion, and community partnership in provider engagement. * Experience working cross-functionally with claims, finance, and contracting teams to address provider payment inquiries, resolve escalations, and implement process improvements related to reimbursement accuracy and timeliness. Compensation Range/Target: $133,600 - $200,400 Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Two or 4 years degree in and IT related fields preferred. A+ and Microsoft certifications are desirable. Demonstrates advanced working knowledge of PC hardware, printers, and networking. Knowledge and experience of the following IT systems is required\: Microsoft operating systems, Microsoft Office, Citrix and other IS infrastructure. Application experience with ITSM (BMC Remedy), Epic, Kronos and Cisco VPN is preferable. Must demonstrate strong interpersonal, verbal communication and problem solving skills and the ability to prioritize and work effectively in a team environment. We take great care of careers. With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge - helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment. Work where every moment matters. Every day, more than 40,000 Hartford HealthCare colleagues come to work with one thing in common\: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut's most comprehensive healthcare network. The creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole, rather than a single member organization. With the creation of our new umbrella organization we now have our own identity with a unique payroll, benefits, performance management system, service recognition programs and other common practices across the system. Position Summary This position interacts with customers who have questions regarding intermediate and advanced infrastructure, hardware, software, network support and troubleshooting issues. Analyst provides first and second level support according to Information Services procedures for customers throughout the Hartford Health Care Corporation enterprise who are in need of assistance. Position reports to the Team Leader. Work from home opportunities available at the discretion of management. Key Accountabilities Works effectively as a team member both within and across the hospital system to promote and integrate Information Services through communication, cooperation and collaboration. Models Hartford HealthCare Service Excellence behaviors in a fast paced environment. Answers all calls in a professional, courteous and timely manner according to department voice etiquette standards. Analyze problem and determine direction to solution solving 70% or more of assigned incidents while showing detailed troubleshooting in the incident notes. Identifies and troubleshoots problems via phone and remote access. Resolves or contacts and assigns to tier II teams in accordance within established department standards. Responsible for resolving complex problems - more in-depth knowledge of hardware, software, applications and infrastructure as defined in documentation. Coordination of work effort among groups, vendors or customers when required for ticket resolution. Create and assign work orders in addition to solving problem tickets. Create knowledge base articles and train co-workers when required

011250 CCA-Claims Hiring for One Year Term **_This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this time._** Working under the direction of the Sr. Director, TPA Management and Claims Compliance, Healthcare Medical Claims Coding Sr. Analyst will be responsible for developing prospective claims auditing and clinical coding and reimbursement edits and necessary coding configuration requirements for Optum CES and Zelis edits. This role will ensure that the applicable edits are compliant with applicable Medicare and Massachusetts Medicaid regulations. The role will also be responsible for timely review and research, as necessary on all new and revised coding logic, related Medicare/Medicaid policies for review/approval through the Payment Integrity governance process. **Supervision Exercised:** + No, this position does not have direct reports. **Essential Duties & Responsibilities:** + Develop enhanced, customized prospective claims auditing and clinical coding and reimbursement policies and necessary coding configuration requirements for Optum CES and Zelis edits. + Quarterly and Annual review and research, as necessary on all new CPT and HCPCS codes for coding logic, related Medicare/Medicaid policies to make recommend reimbursement determinations. + Analyze, measure, manage, and report outcome results on edits implemented. + Utilize data to examine large claims data sets to provide analysis and reports on existing provider billing patterns as compared to industry standard coding regulations, and make recommendations based on new/revised coding edits for presentation to Payment Integrity committee meetings. + Analyze, measure, manage, and report outcome results on edits implemented. + Use and maintain the rules and policies specific to CES and Zelis. + Query and analyze claims to address any negative editing impacts and create new opportunities for savings based on provider billing trends + Liaison between business partners and vendors; bringing and interpreting business requests, providing solutioning options and documentation, developing new policies based on State and Federal requirements, host meetings, and managing projects to completion + Define business requests received, narrow the scope of the request based on business needs and requirements, provider resolution option based on financial ability and forecasting for small to large Operations Management + Collaborate system and data configuration into CES (Claims Editing System) with BPaaS vendor and other PI partners, perform user acceptance testing, and analyze post production reports for issues + Support collaboration between PI/Claims and other internal stakeholders related to the identification and implementation of cost-savings initiatives specific to edits. **Working Conditions:** + Standard office conditions. Remote opportunity. **Other:** + Standard office equipment + None/stationary **Required Education (must have):** + Bachelor's Degree or Equivalent experience Ideal Candidate to have the one or all of the required certification OR willing to get certified within 1 year of employment - + Certified Professional Coder (CPC) + Certified Inpatient Coder (CIC) + Certified Professional Medical Auditor (CPMA) **Desired Education (nice to have):** + Masters Degree **Required Experience (must have):** + 7+ years of Healthcare experience, specific to Medicare and Medicaid + 7+ years progressive experience in medical claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required + 7+ years experience with Optum Claims Editing System (CES), Zelis, Lyric or other editing tools + Extensive knowledge and experience in Healthcare Revenue Integrity, Payment Integrity, and Analytics + 5+ years of Facets Claims Processing System **Required Knowledge, Skills & Abilities (must have):** + Knowledge and experience of claim operations, health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare) + Medical Coding, Compliance, Payment Integrity and Analytics + Direct and relevant experience with HCFA/UB-04 claims management, coding rules and guidelines, and evaluating/analyzing claim outcome results for accurate industry standard coding logic and policies (i.e . Center for Medicare & Medicaid Services (CMS) & MA Medicaid, Correct Coding Initiative (CCI), Medically Unlikely Edits (MUEs) both practitioner and facility, modifier to procedure validation, and other CMS and American Medical Association (AMA) guidelines, etc.) + Advanced experience of medical terminology and medical coding (CPT, HCPCS, Modifiers) along with the application of Medicare/Massachusetts Medicaid claims' processing policies, coding principals and payment methodologies + Ability to work cross functionally to set priorities, build partnerships, meet internal customer needs, and obtain support for department initiatives + Ability to plan, organize, and manage own work; set priorities and measure performance against established benchmarks + Ability to communicate and work effectively at multiple levels within the company + Customer service orientation; positive outlook, self-motivated and able to motivate others + Strong work ethic; able to solve problems and overcome challenges **Required Language (must have):** + English **Compensation Range/Target: $64,000 - $96,000** Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. EEO is The Law Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

011230 CA-Provider Engagement & Performance The Provider Relations Liaison is responsible for cultivating, maintaining and strengthening relationships with the Commonwealth Care Alliance's (CCA) provider community. In this highly visible field position, the provider relations specialist acts as the primary liaison between CCA and its providers including primary care practices, specialists, physician organizations, hospitals, ancillary and LTSS providers. Key responsibilities include establishing positive working relationships with providers, effectively communicating with and educating those providers about CCA and resolving provider inquiries. Supervision Exercised: No Essential Duties & Responsibilities Develop strong professional relationships with all providers and their staff while functioning as a liaison to the provider community to research and resolve complex provider issues. Take ownership of the provider relationship, ensuring all provider needs and concerns are addressed and answered. Establish regular contact with and visits to provider sites. Visits may include regular operations meetings, staff education, provider orientations, and appreciation events. Facilitate and lead orientation meetings and communication sessions with key providers; orient providers on CCA's policies related to: Claims and service recovery; Program benefits; Clinical initiatives; Referral and authorization; Regulatory compliance; Billing and payments; Complaints and appeals; Policies and procedures. Identify opportunities for training and education. Conduct site visits with contracting, sales and marketing departments to ensure the collection of required applications and other documentation. Manage and respond to a high volume of provider inquiries while ensuring consistent follow through on resolution of issues. Represent CCA at provider related events and other initiatives, as necessary. Prioritize and organize own work to meet deadlines. Work collaboratively with Provider Network Management staff to ensure an adequate and appropriate provider network. Participate in contracting strategy discussions around potential recruitment opportunities. Coordinate with other CCA departments, including Clinical Management, Member Services, Regulatory Affairs, Claims and Outreach and Marketing, to resolve provider issues. Participate in departmental and interdepartmental meetings as appropriate and necessary Participate in the development of departmental policies, procedures and processes. Special projects as assigned or directed. Maintain professional growth and development. Working Conditions: Standard office conditions. Education (Required): Bachelor's Degree or equivalent experience Experience (Required) 3-5 years Managed Care experience Experience in health plan provider relations. Experience (Desired) Medicare/Medicaid experience preferred. Experience with CPT coding and authorization process highly desired. Experience with and understanding of Claims operations preferred. Knowledge, Skills & Abilities (Required) Understanding of provider office operations as they relate to health plans Knowledge of billing practices and reimbursement methodologies. Excellent verbal, written and presentation skills. Outstanding Customer Service Skills. Intermediate Microsoft Office competency, including Outlook, Word, Excel & Power Point. Ability to multi-task. Ability to work independently. Ability to interact well with individuals on all levels, and maintain a professional image and attitude. Strong analytical, problem solving and project management skills. Detail oriented, with the ability to organize and manage multiple priorities. Language(s): English Fluency Other: Valid Driver's license and reliable insured automobile required Must be able to travel within an assigned territory on a daily basis. Compensation Range/Target: $54,800 - $82,200 Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.