Commonwealth Care Alliance jobs in Providence, RI

011230 CA-Provider Engagement & Performance The Program Manager, in collaboration with the Sr Director of Delegation Partnerships and Performance, is responsible for advancing provider quality performance across CCA's contracted network, with a focus on value-based arrangements and network-wide engagement strategies. The program manager is responsible for managing and implementing key population health and network quality initiatives to achieve high performance on CCA's Population Health goals; including Medicare Star measures, Medicaid-Medicare Plan withhold measures, quality performance metrics incorporated into other CCA contracts, health equity, Culturally and Linguistically Appropriate Services, Consumer Assessment of Healthcare Providers and Systems (CAHPS), and social determinants of health (SDOH) measures. The Program Manager will work collaboratively with our provider network and Quality teams to identify quality metrics that align contracting efforts for efficiency and effectives with alternative payment models. The Program This role serves as a critical bridge between Provider Engagement, Network Performance, Analytics, Clinical and Quality Teams to drive improvement in clinical outcomes, health equity, and member and provider experience. Supervision Exercised No direct reports currently; however, one to three program consultants with future expansion. Essential Duties & Responsibilities: Provider Quality Performance and Value-Based Care Lead implementation and monitoring of quality initiatives tied to value-based payment programs and contractual performance metrics. Partner with Provider Engagement, Network, Clinical and Quality teams to evaluate provider performance, identify opportunities for improvement, and facilitate data-driven action plans. Collaborate with Contracting, Quality Analytics, and Population Health to align provider quality measures with value-based contracts and incentive programs. Translate quality performance data into actionable insights and communicate findings to provider partners to drive improvement. Support the development and oversight of provider pay-for-performance programs, including metric tracking, financial reconciliation, and performance reporting. Health Equity and CLAS Integration Partner with the Health Equity team to incorporate CLAS (Culturally and Linguistically Appropriate Services) standards into provider education and engagement activities. Lead or support the development and dissemination of provider-facing resources that advance equitable care delivery. Coordinate provider training and communication initiatives focused on social drivers of health, cultural competence, and equity-focused performance improvement. CAHPS Strategy and Performance Oversee implementation of provider-focused initiatives that support CAHPS performance improvement. Analyze CAHPS results to identify trends and collaborate with Provider Network, Clinical and Quality teams to address performance gaps. Develop and disseminate provider education and best practices to improve member satisfaction with access, communication, and care coordination. Track and report provider performance metrics related to CAHPS domains such as Getting Needed Care, Getting Care Quickly, Rating of Health Care, and Customer Service. Collaborates with Communications to design provider materials and newsletters reinforcing CAHPS-related expectations and improvement goals. Partners with network leadership to recognize high-performing providers and share improvement strategies. Provider Education and Engagement Manage the design, scheduling, and delivery of provider quality education, including webinars, learning sessions, and quality performance updates in collaboration with Quality team. Develop materials and presentations that clearly communicate quality goals, contractual expectations, and best practices to the provider network. Serve as a trusted liaison to provider partners, responding to quality-related inquiries and facilitating collaborative discussions on improvement opportunities. Performance Reporting & Data Management Partner with Quality Analytics and Business Intelligence to ensure timely, accurate, and meaningful quality performance reporting to internal teams and providers. Monitor performance trends and support the creation of dashboards, summaries, and progress reports for internal and external audiences. Maintain documentation, SOPs, and reporting schedules to support consistent quality operations. Cross-Functional Collaboration & Strategic Support Collaborate closely with Provider Engagement, Contracting, Quality, and Clinical to ensure alignment on provider quality goals. Participate in cross-functional workgroups focused on quality improvement, network performance, and member and provider experience. Support strategic initiatives that promote continuous improvement and operational efficiency across the provider network. Working Conditions Remote or hybrid working conditions. Position requires occasional travel in Massachusetts and the surrounding area. Required Education: Bachelor's degree in healthcare administration, public health, business or health care related field Desired Education: Master's degree Certified Professional in Healthcare Quality (CPHQ) or equivalent certification Required Experience: 5-7 years of experience in healthcare quality improvement, provider network performance and management, population health, or related area Demonstrated experience interpreting and applying quality measures (HEDIS, CAHPS, HOS) and value-based contract performance metrics Experience with Medicare Advantage, Medicaid; and dually eligible populations Desired Experience Experience managing or supporting pay-for-performance or value-based care programs. Experience leading provider education or training sessions. Exposure to health equity initiatives and/or CLAS standards integration in provider settings. Required Knowledge, Skills & Abilities: Strong understanding of provider quality performance frameworks and value-based care principles. Working knowledge of claims data, quality measurement, and performance incentive methodologies. Excellent verbal and written communication skills, including the ability to synthesize and present data effectively to providers and internal stakeholders. Strong relationship management and interpersonal skills; ability to engage diverse provider partners diplomatically. Proficiency with Microsoft Office Suite (Excel, PowerPoint, Word) and comfort working with dashboards and analytics tools. Proven project management skills and ability to manage multiple priorities and deadlines. Self-directed, detail-oriented, and able to work effectively in a fast-paced, matrixed environment. Desired Knowledge, Skills & Abilities: Familiarity with quality analytics platforms, provider portals, or data visualization tools. Working knowledge of health plan claims and payment policies, including provider reimbursement methodologies. Experience applying CLAS standards or health equity frameworks within provider engagement or quality improvement initiatives. Language(s) English 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.

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.

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.

011330 CCA-Clin Operations & Implementation This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this time. The Clinical Operations Support Department (CS) is responsible for providing analytical and operational support to different departments within Clinical Operations in order to maximize productivity and to ensure regulatory compliance. The Senior Business Analyst, Clinical Operations reports to the Director, Clinical Operations Support. This role will provide significant BA support to key business units within Clinical Operations, including reports and analytics to ensure continuous process improvement. As a senior individual contributor on the team, the Senior Analyst is expected to successfully lead projects of any size, scope, and level of complexity, directly engaging with senior leaders of the highest level. He/she is also expected to mentor and guide more junior members of the team. This role is for an independent self-driven contributor who will lead delivery of projects/reports/analytics and may work independently or in matrixed cross functional team. The expectation is this person can lead a workgroup and mentor team members, as needed Supervision Exercised: None Essential Duties & Responsibilities Reports and Tools Engages with stakeholders to understand current processes/systems and pain points as well as elicit detailed business needs of/gather requirements for reports and tools. Develops reports by querying the database using SQL or any related programming language and analyzing data to ensure accuracy Creates visualizations using Tableau, Looker, Excel Data Analysis Analyzes large sets of data, summarizes and presents results. Develops and analyzes quantitative reports to assess utilization, productivity and adherence to policies and procedures related to various topics such as, authorizations, assessments, procurement, etc. Tracks, analyzes and resolves claims issues related to prior authorizations. Process Improvement Partners with Clinical Operations management to develop and review workflows, to streamline processes and increase efficiency. Generate insights and developing recommendations for solutions Create Visio diagrams or other visualizations to use in prototype review sessions Liaison between Clinical Operations and Other Departments Plays a leadership role in developing and managing major Clinical Operations Analytic projects Serve as liaison between Business Intelligence team and various departments within Clinical Operations. He/she is expected to translate the business needs into BI requirements for reports, dashboards and tools. Education (Required) Bachelor's Degree in information systems or related quantitative field required (Business, Computer Science, Mathematics, Finance, Economics, or similar) Experience (Required) 5 years minimum experience with at least 2 years in demonstrated a leadership role Demonstrated progression of leadership, responsibility, knowledge, and experience Demonstrated experience in understanding business needs and documenting requirements for reports and tools. 5 years of programming experience in SQL or any related programming language 5 years of experience in developing and using large relational database modeling concepts and practices Demonstrated experience with data or statistical analysis in healthcare industry/operations Demonstrated experience with BI products like, Tableau, Alteryx, Looker Demonstrated experience in developing and using large relational databases Experience with Google Cloud (big query) preferred Knowledge, Skills & Abilities (Required) Expertise with technical programming languages such as SQL or any related language Advanced knowledge of Excel, including the use of Macros and VBA Proven ability to summarize data and build effective visualizations Proven ability to translate business needs into BI requirements Knowledge of operations in healthcare preferred Knowledge of R, Python and SAS preferred Strong problem-solving skills Proven skills and judgment necessary for independent decision-making Strong communication skills both written and verbal Language(s): English required, bilingual preferred. 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.

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)

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.

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. 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.

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.

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. 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 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.

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.

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) 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.

011330 CCA-Clin Operations & Implementation **_This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this time._** The Clinical Operations Support Department (CS) is responsible for providing analytical and operational support to different departments within Clinical Operations in order to maximize productivity and to ensure regulatory compliance. The Senior Business Analyst, Clinical Operations reports to the Director, Clinical Operations Support. This role will provide significant BA support to key business units within Clinical Operations, including reports and analytics to ensure continuous process improvement. As a senior individual contributor on the team, the Senior Analyst is expected to successfully lead projects of any size, scope, and level of complexity, directly engaging with senior leaders of the highest level. He/she is also expected to mentor and guide more junior members of the team. This role is for an independent self-driven contributor who will lead delivery of projects/reports/analytics and may work independently or in matrixed cross functional team. The expectation is this person can lead a workgroup and mentor team members, as needed **Supervision Exercised:** None **Essential Duties & Responsibilities** **Reports and Tools** + Engages with stakeholders to understand current processes/systems and pain points as well as elicit detailed business needs of/gather requirements for reports and tools. + Develops reports by querying the database using SQL or any related programming language and analyzing data to ensure accuracy + Creates visualizations using Tableau, Looker, Excel **Data Analysis** + Analyzes large sets of data, summarizes and presents results. + Develops and analyzes quantitative reports to assess utilization, productivity and adherence to policies and procedures related to various topics such as, authorizations, assessments, procurement, etc. + Tracks, analyzes and resolves claims issues related to prior authorizations. **Process Improvement** + Partners with Clinical Operations management to develop and review workflows, to streamline processes and increase efficiency. + Generate insights and developing recommendations for solutions + Create Visio diagrams or other visualizations to use in prototype review sessions **Liaison between Clinical Operations and Other Departments** + Plays a leadership role in developing and managing major Clinical Operations Analytic projects + Serve as liaison between Business Intelligence team and various departments within Clinical Operations. He/she is expected to translate the business needs into BI requirements for reports, dashboards and tools. **Education (Required)** + Bachelor's Degree in information systems or related quantitative field required (Business, Computer Science, Mathematics, Finance, Economics, or similar) **Experience (Required)** + 5 years minimum experience with at least 2 years in demonstrated a leadership role + Demonstrated progression of leadership, responsibility, knowledge, and experience + Demonstrated experience in understanding business needs and documenting requirements for reports and tools. + 5 years of programming experience in SQL or any related programming language + 5 years of experience in developing and using large relational database modeling concepts and practices + Demonstrated experience with data or statistical analysis in healthcare industry/operations Demonstrated experience with BI products like, Tableau, Alteryx, Looker + Demonstrated experience in developing and using large relational databases + Experience with Google Cloud (big query) preferred **Knowledge, Skills & Abilities (Required)** + Expertise with technical programming languages such as SQL or any related language + Advanced knowledge of Excel, including the use of Macros and VBA + Proven ability to summarize data and build effective visualizations + Proven ability to translate business needs into BI requirements + Knowledge of operations in healthcare preferred + Knowledge of R, Python and SAS preferred + Strong problem-solving skills + Proven skills and judgment necessary for independent decision-making + Strong communication skills both written and verbal **Language(s):** English required, bilingual preferred. **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 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.

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. 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 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.

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 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.