field_remote_option

field_job_occupational_field_parents_all

job_organization_name

job_upgrade_is_featured

<h1>Provider Services - Supervisor Credentialing 115-4004</h1> Tulsa, OK, USA Req #641 Monday, March 31, 2025 JOB SUMMARY: Responsible for supervising credentialing personnel and oversight of training. Supervise workflows and projects to support timely, efficient production. Responsible for ensuring credentialing policies and procedures are compliant with regulatory agencies and accreditation standards. KEY RESPONSIBILITIES: <ul> <li> Provide day-to-day supervision of personnel. Evaluate performance of direct reports and provide regular feedback individually and to the team.Identify improvement opportunities to support continuous development.Assists in the maintenance of MD Staff Software to ensure quality provider data. Responsible for updating policies and procedures with regard to all credentialing and provider data processes. </li> <li> Assists in coordinating the agenda, reporting and follow-up of activities related to the Credentials Committee.Responsible for ongoing sanctions review of all providers through internal monitoring activities. Coordinate, assist in, and follow up of the weekly audit of credentialing files. </li> <li>Responsible for supervision, including monitoring and assessing reports, to ensure providers are credentialed in accordance with state mandates, and policy and procedures. Responsible for oversight of initial processes, reappointment processes, and CAQH utilization.</li> <li>Report on credentialing activities and performance to the appropriate internal committees. Responsible for interdepartmental communication to provide and receive assistance regarding credentialing applications for both initial and reappointment applications. Responsible for processing credentialing related invoices and statement, including Credentials Committee Stipends, for appropriate approvals and submission to Accounts Payable.</li> <li>Assists in the Delegated Credentialing Oversight activities.</li> <li>Perform other duties as assigned. </li> </ul> QUALIFICATIONS: <ul> <li>Ability to effectively supervise others, to include the ability to maintain a positive working environment, project a positive attitude, and be a self-starting individual and maintain a team player attitude.</li> <li>Ability to work within cross-functional teams and to build effective working relationships to achieve performance objectives.</li> <li>Possess strong oral and written communication skills with an ability to interpret and communicate information effectively, including with all levels of employees as well as external stakeholders.</li> <li>Ability to handle confidential information in a professional and sensitive manner.</li> <li>Basic knowledge in Microsoft applications. </li> </ul> EDUCATION/EXPERIENCE: <ul> <li>3 years of experience in managed care, health insurance and/or health care setting</li> <li>Previous credentialing experience</li> <li> Associate’s degree in business, healthcare or related fieldpreferred </li> <li> 2 years supervision experience preferred </li> <li>Certification in credentialing (CPMSM or CPCS) preferred</li> </ul> CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin <h2 id="otherDetailsHeader">Other details</h2> <ul> <li> Job Family Commercial </li> <li> Pay Type Salary </li> </ul> <a href="#"> Apply Now </a>

CommunityCare

Provider Services - Supervisor Credentialing 115-4004

<h1>Executive Dept - Senior VP &amp; Chief Financial Officer</h1> Tulsa, OK, USA Req #786 Tuesday, April 1, 2025 JOB SUMMARY: Plans, organizes, manages, and leads the activities of various operational functions of the company including Finance, Underwriting, Financial Analysis, Investments, and Reporting. Significant emphasis of this role surrounds financial reporting and analysis of budgeting, accounting, financial systems development, internal controls, and maintenance of records and procedures to adequately safeguard the assets of the organization. The CFO will provide financial leadership and direction to the organization, along with the President and CEO, and will also serve as a strategic financial partner to the executive team and departments. KEY RESPONSIBILITIES: <ul type="disc"> <li>Reviews performance against operating budget and business plans. Provides feedback and makes necessary changes to ensure that the operating budget and business plans are achieved and align with the strategies of the organization. </li> <li>Contributes to the overall effective strategy for specific operational functions. Implements the strategy to ensure optimal operational performance in all appropriate areas. </li> <li>Maintains a positive working relationship and rapport with key owner representatives and works toward ensuring that requests are completed in a timely and efficient manner. </li> <li>Accountable for the short and long range financial and capital plans in conjunction with, and support of, the </li> <li>organization’s strategic and operational objectives and key performance indicators. </li> <li>Develops managerial talent through effective coaching and development, along with succession planning, and works toward ensuring that resources and work processes are being utilized effectively and efficiently. </li> <li>Works closely with all internal stakeholders to ensure that contracts are completed timely and achieve the quality, access, and financial objectives of the company. </li> <li>Coordinates the Finance Department closely with Provider Relations to ensure that changes in provider contracts are considered in the operating budget. </li> <li>Serves as a member of the executive leadership team working collaboratively to achieve the mission of CommunityCare. </li> <li>Monitors utilization statistics and financial analysis with ability to develop action plans to address areas of concern. </li> <li>Attends and presents at the meetings of the Board of Directors and Committees of the Board as directed by the President &amp; CEO and performs other duties as assigned. </li> <li>Completes other projects and initiatives as directed by the President &amp; CEO. </li> </ul> QUALIFICATIONS: <ul type="disc"> <li>Proven administrative skills, analytical skills, and problem solving with emphasis on team building, ensuring accountability throughout areas of responsibility. </li> <li>Well versed in the financial challenges of health care. </li> <li>Ability and desire to drive and direct a high performance financial organization. </li> <li>Ability to reinforce a culture of transformation, measurement, accountability, and service. </li> <li>Excellent oral and written communication skills. </li> <li>Strong strategic mindset with quality planning, implementation, and execution skills. </li> <li>Ability to sustain a high level of energy and performance. </li> <li>Exceptional interpersonal skills with ability to quickly build relationships and rapport with stakeholders. </li> <li>Demonstrated ability to recruit, train, develop, motivate, and progress a management team. </li> <li>Ability to converse and write fluently in English. </li> </ul> EDUCATION/EXPERIENCE: <ul type="disc"> <li>Master’s degree in Finance, Accounting, Business and /or Healthcare Administration or equivalent strongly preferred. </li> <li>At least 10 years of related experience in the managed care industry, preferably in a executive leadership role within finance. </li> <li>At least 3 years in a complex healthcare or preferably health insurance setting as a C-level leadership position with multi-departmental responsibilities. </li> <li>Experience in a provider-sponsored plan including capitation model knowledge is preferred. </li> <li>CPA highly recommended and preferred. </li> </ul> CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin <h2 id="otherDetailsHeader">Other details</h2> <ul> <li> Job Family Commercial </li> <li> Pay Type Salary </li> </ul> <a href="#"> Apply Now </a>

Executive Dept - Senior VP & Chief Financial Officer

<h1>Reporting - Senior Health Data Analyst 135-2031</h1> Tulsa, OK, USA Req #575 Monday, March 31, 2025 JOB SUMMARY: The Senior Health Data Analyst provides the analytical support for Executives and all departments including analysis, pricing, capitation, network, and provider specific reporting. Analytical support includes programming customer-based specifications, producing appropriate statistics, reports, and presentations, analyzing results and impacts, and generating written reports with recommendations and conclusions. The Senior Analyst works with data in company and other databases, data cleaning, descriptive statistical analysis, data modeling, developing and maintaining data documentation, and comparing results to industry standards. The Senior Analyst is also responsible for managing high complexity projects requiring team effort of several other analysts and involvement from other departments. In addition, responsibility of quality review and mentoring are expected. The quality review and mentoring process includes code and logic review, benchmarking, and direction and insight of the reporting processes, statistics of healthcare, and managing projects requiring limited level of independent decision making and coordinating resources. KEY RESPONSIBILITIES: <ul> <li>Manage projects, including create and lead a team of analysts, interact with other departments and outside parties. </li> <li>Concurrently conduct multiple major analytical projects without immediate supervision, including all aspects from programming to analyzing and abstracting information into written reports. </li> <li>Perform review and quality assurance of the projects assigned to other analysts.</li> <li>Develop reports and ad-hoc analysis based on specifications outlined by department management. Automate such reports and ensure that they are performed and delivered on schedule. </li> <li>Create presentations of data analysis including conclusions and recommendations and present findings to key stakeholders.</li> <li>Serve as a resource and mentor to other analysts and assist in training and development as needed.</li> <li>Perform other duties as assigned.</li> </ul> QUALIFICATIONS: <ul> <li>Ability see major analysis projects through to completion without immediate supervision.</li> <li>Ability to independently manage projects, including creating and leading a team of analysts, interaction with other departments and outside stakeholders.</li> <li>Ability to apply advanced actuarial, mathematical and statistical techniques and principles into the analysis of financial and health related data.</li> <li>Possess strong oral and written communication skills with the ability to communicate results in a consistent and professional manner.</li> <li>Proven ability to perform descriptive analytics.</li> <li>Demonstrated knowledge of programming, running and modifying pre-written and new code required.</li> <li>Demonstrated knowledge of healthcare data.</li> <li>Ability to converse and write fluently in English.</li> <li>Successful completion of Health Care Sanctions background check.</li> <li>Proficient in Microsoft Office applications.</li> </ul> EDUCATION/EXPERIENCE: <ul> <li>Bachelor’s degree required. Mathematics, Statistics, Economics, Actuarial Science or other quantitative discipline preferred. Master’s degree a plus.</li> <li>Demonstrated use of analytical software. SAS or SQL preferred.</li> <li>Experience in Power BI, Tableau or similar software preferred.</li> <li>5 plus years of Health Data or Data Analysis experience.</li> <li>Project management experience preferred. </li> </ul> CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin <h2 id="otherDetailsHeader">Other details</h2> <ul> <li> Job Family Commercial </li> <li> Pay Type Salary </li> </ul> <a href="#"> Apply Now </a>

Reporting - Senior Health Data Analyst 135-2031

<h1>Marketing - Account Manager 110-2004</h1> Tulsa, OK, USA Req #721 Friday, March 14, 2025 JOB SUMMARY: Responsible for helping CommunityCare achieve membership growth targets by meeting or exceeding goal levels for the retention of enrolled groups and members. The incumbent is responsible for establishing positive business relationships with decision makers and decision influencers at enrolled groups, as well as with producers and consultants associated with enrolled groups. Must be willing to learn and grow into roles of increasing responsibility. KEY RESPONSIBILITIES: <ul> <li>Establishing positive business relationships with strategic decision makers and influencers at enrolled groups. </li> <li>When requested, coordinates the resolution of a variety of problems involving claims, membership and billing outcomes presented by groups and producers. Effectively channels these issues to the appropriate CommunityCare area for the most efficient handling possible. </li> <li>Works with sales representatives to create smooth transitions between new group sales and new group implementations. Conducts employee meetings at new and enrolled groups. Proactively schedules large group annual open enrollment meetings to avoid conflicts. </li> <li>Communicates and validates the value of ComuntiyCare's benefits plans, including compiling specialized reports for groups, producers and consultants. Maintains a knowledge of the actuarial and underwriting basis for calculating renewals and renewal options. </li> <li>Coordinates a variety of wellness activities and health benefit fairs. Perform other duties as assigned. </li> <li>Works with internal departments to establish changes required to create successful renewal outcomes that are viable for all involved. </li> <li>Perform other duties as assigned.</li> <li>Works with Account Management Team to achieve departmental and team goals.</li> </ul> QUALIFICATIONS: <ul> <li>Strong oral and written communications skills.</li> <li>Self-motivated and able to work with minimal supervision.</li> <li>Successful completion of a Motor Vehicle Record Check.</li> <li>Successful completion of Health Care Sanctions background</li> <li>check.</li> <li>Must have a current driver's license and vehicle insurance</li> <li>verification.</li> <li>Ability to converse and write fluently in English.</li> <li>Must be a proven team player.</li> </ul> EDUCATION/EXPERIENCE: <ul> <li>Associate's degree in Business, Marketing or related discipline OR one year of industry relevant, work related experience may be substituted for every year of college not completed.</li> <li>1-2 years’ experience working in marketing, benefits, health care or customer service preferred.</li> <li>Licensed Life and Health insurance agent in state of Oklahoma, or ability to obtain within 45 days after hire date.</li> </ul> CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin <h2 id="otherDetailsHeader">Other details</h2> <ul> <li> Job Family Commercial </li> <li> Pay Type Salary </li> </ul> <a href="#"> Apply Now </a>

Marketing - Account Manager 110-2004

<h1>Provider Services - Supervisor Provider Contracting 115-4000 </h1> Tulsa, OK, USA Req #765 Tuesday, March 18, 2025 JOB SUMMARY: Responsible for the negotiation, execution and implementation of all HMO, PPO and Government Programs, provider contracts including value based and complex. Responsible for the supervision (planning, execution, implementing and monitoring) of all aspects of the provider contracting staff. Responsible for contract related processes and procedures under the direction of the Director, Provider Relations. Responsible for ensuring provider contracting is performed in compliance with all regulatory requirements and accreditation standards. KEY RESPONSIBILITIES: <ul> <li>Supervises and facilitates contract negotiations, contract document processes and ongoing deliverables for provider contracts for all assigned product lines as directed by Director, Provider Relations in accordance with all regulatory requirements and accreditation standards. Responsible for oversight of production, documentation, audit, implementation, and ongoing contract deliverables related to contracting process. Ongoing assessment of resource allocation to ensure that the process is working as designed with continual awareness of process improvement opportunities. Operationalize contract related projects assigned by Director, Provider Relations.</li> <li>Facilitates and coordinates all value based and complex provider contracting according to and within company guidelines as directed by the Director, Provider Relations. Facilitates reimbursement analysis and recommends provider reimbursement mechanisms. Assists with development of network contracting models including capitation allotment and value-based incentive mechanisms. Develops financial and utilization review report requests. Responsibilities include accurate document development, coordinating with Management and provider, accurate and prompt implementation of all aspects of owned contracts.</li> <li>Supervision and development of contracting staff. Participates in the hiring process. Trains, assigns tasks and supports continuing professional development. Evaluate performance and recommend needed personnel actions. Document appropriately. Monitor staffing needs and workflow and recommend changes as needed. Distribute information to subordinates appropriately and in a timely manner to facilitate their job needs. Delegate tasks/projects appropriately to promote personal growth. Model and promote behavior supportive of a teamwork concept.</li> <li>Participate in the development of new and existing provider networks to ensure appropriate access and availability for all enrolled lives. Participate in assessing requests and initiating requests for addition of services and providers for all product lines. Participates in the assessment of access and availability of services. Support organizational and departmental goals and objectives related to securing appropriate network panels and budget sensitive reimbursement through timely response to administrative and departmental contract requests and projects.</li> <li>Support business operations. Attend information and implementation meetings. Communicate information interdepartmentally and follow through on required action items. Communicate trends and specific incidents impacting company risk management to the appropriate parties. Design and implement policies and procedures contributing to improved efficiency. Monitor departmental compliance to accreditation and regulatory agencies and adjust staffing, policies and procedures as needed. Participate in special projects.</li> </ul> QUALIFICATIONS: <ul> <li>Ability to process and understand complex information. Ability to organize and oversee multiple complex tasks/projects to completion.</li> <li>Ability to coordinate resources in an effective, cost-efficient manner.</li> <li>Excellent communication and interpersonal skills.</li> <li>Ability to interpret and communicate detailed technical and financial information.</li> <li>Demonstrated knowledge of physician and hospital capitation reimbursement methodologies.</li> <li>Familiarity with healthcare and managed care business operation environments.</li> <li>Strong familiarity with managed care terminology.</li> <li>Proficiency with software systems including Amisys, Microsoft Word and Excel.</li> <li>Ability to converse and write fluently in English.</li> </ul> EDUCATION/EXPERIENCE: <ul> <li>Bachelor’s degree plus 3 years work related experience.</li> <li>Supervisory experience required.</li> <li>Demonstrate through past performance and progressive increased in responsibility, the ability to accomplish goals.</li> <li>Excellent oral presentation and writing skills.</li> <li>Previous physician/hospital contracting, claims processing, or reimbursement development and auditing experience.</li> <li>Familiarity with providers and provider issues in a managed care environment.</li> <li>Previous claims software experience, preferably Amisys.</li> </ul> CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin <h2 id="otherDetailsHeader">Other details</h2> <ul> <li> Job Family Commercial </li> <li> Pay Type Salary </li> </ul> <a href="#"> Apply Now </a>

Provider Services - Supervisor Provider Contracting 115-4000

<h1>Information Technology - Senior Programmer Analyst 130-2009</h1> Tulsa, OK, USA Req #761 Tuesday, March 18, 2025 JOB SUMMARY: Focus on the development and support of new and existing Database Management Systems (DBMS). Responsible for the design, development and implementation of new applications as well as maintaining and updating existing programs. KEY RESPONSIBILITIES: <ul> <li>Perform Oracle DBA Functions</li> <li>Design and analysis of critical Database Management Systems (DBMS) related to the AMISYS systems and surround code programs.</li> <li>Design, code, test, maintain and document structured desktop and web programs using various applications software. Take written program specifications and develop working applications to be implemented for the end-users. </li> <li>Work with end-users to determine their specific requirements and needs. Document those requirements and develop written program specifications from them. Maintain and update existing applications as needed or requested by end-users. </li> <li>Train end-users on newly developed and existing applications.</li> <li>Required to be on call 24/7. May be contacted by phone or email. May receive up to 3 to 4 calls per week.</li> <li>Perform other duties as assigned.</li> </ul> QUALIFICATIONS: <ul> <li>Skills in project management.</li> <li>Understanding of mathematical concepts and skills in abstract reasoning.</li> <li>Successful completion of Health Care Sanctions background check.</li> <li>Proficient in personal computer applications, Windows/Client Server programming languages, and database design.</li> <li>Excellent problem solving and organizational skills.</li> <li>Ability to communicate technical information to users in concise understandable terms.</li> <li>Ability to work as a team member in a high paced environment.</li> <li>Must be able to maintain and preserve information of a highly confidential nature.</li> <li>Ability to converse and write fluently in English.</li> </ul> EDUCATION/EXPERIENCE: <ul> <li>Bachelor’s degree, Masters degree preferred.</li> <li>5 years related systems experience. Project management experience preferred.</li> </ul> CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin <h2 id="otherDetailsHeader">Other details</h2> <ul> <li> Job Family Commercial </li> <li> Pay Type Salary </li> </ul> <a href="#"> Apply Now </a>

Information Technology - Senior Programmer Analyst 130-2009

<h1>Medical Management - Concurrent Review Nurse- RN 145-2018</h1> Tulsa, OK, USA Req #776 Tuesday, March 18, 2025 JOB SUMMARY: Responsible for clinical review of utilization requests and assessment and implementation of potential coordination of care opportunities for overall membership, institutionalized populations, high risk members, and other members identified with at risk or high utilization needs. Functions as an active team member of the Concurrent Review Team. KEY RESPONSIBILITIES: <ul> <li>Performs utilization review of inpatient, post-acute, outpatient and ancillary services.</li> <li>Determines medical necessity and appropriateness of services using clinical review criteria.</li> <li>Accurately documents all review determinations and contacts providers and members according to established timeframes.</li> <li>Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director.</li> <li>Appropriately identifies and refers quality issues to Medical Management leadership.</li> <li>Appropriately identifies potential cases for Care Management programs.</li> <li>Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum.</li> <li>Performs accurate data entry.</li> <li>Communicates appropriate information to other staff members as necessary/required.</li> <li>Participates in continuing education initiatives.</li> <li>Collaborates with other departments as needed.</li> <li>Performs other duties as assigned.</li> </ul> QUALIFICATIONS: <ul> <li>Knowledge of managed care and associated group benefit plans.</li> <li>Possess strong oral and written communication skills.</li> <li>Ability to reason logically and to use good judgment when interpreting materials or situations.</li> <li>Knowledge of community- based resources.</li> <li>Must have excellent organizational skills and be able to perform multiple tasks.</li> <li>Proficient in Microsoft applications.</li> <li>Excellent time management and documentation skills.</li> <li>Successful completion of Health Care Sanctions background check.</li> </ul> EDUCATION/EXPERIENCE: <ul> <li>Graduation from accredited School of Nursing.</li> <li>Current, active, unrestricted license to practice as a Registered Nurse in the State of Oklahoma.</li> <li>Three years of acute care experience preferred.</li> <li>Two years of experience working with population health preferred.</li> <li>Previous discharge planning or case management experience preferred.</li> <li>Managed care experience a plus.</li> </ul> CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin <h2 id="otherDetailsHeader">Other details</h2> <ul> <li> Job Family Commercial </li> <li> Pay Type Salary </li> </ul> <a href="#"> Apply Now </a>

Medical Management - Concurrent Review Nurse- RN 145-2018

<h1>Medical Management - Supervisor Medical Review 145-4005</h1> Tulsa, OK, USA Req #762 Tuesday, March 18, 2025 The Medical Review Supervisor is responsible for overseeing activities and personnel involved in the day to day operations of CommunityCare’s medical claim review program. The Supervisor guides individuals in implementing auditing and monitoring functions aimed at identifying areas of risk and/or potential fraud, waste and abuse, as it relates to provider billing practices. KEY RESPONSIBILITIES: <ul> <li>Provides technical expertise to Medical Review (MRE) staff including analysis, problem solving, and decision making of complex claim reviews. Identifies medical necessity and /or quality issues for further evaluation. Oversees triage of pended and high dollar claims. Collaborates with external vendors on cases meeting reinsurance thresholds and specific requirements for ASO lines of business.</li> <li>Works collaboratively with other departments in providing or seeking claims review and/or clinical guidance. Participates in company committees or work groups as assigned.</li> <li>Proactively conducts routine monitoring and identifies areas of potential fraud, waste and/or abuse (FWA). Formulates recommendations based on findings. Suggests opportunities for focused reviews. Works collaboratively with the Compliance Officer and/or Special Investigations (SIU) as needed.</li> <li>Coordinates and/or oversees daily activities of the MRE staff. This includes planning, implementing and evaluating MRE goals. It also includes monitoring workload, staff supervision, training, coaching, auditing, teambuilding, performance evaluation and hiring/retaining staff. Provides training for new MRE staff including one-to-one sessions as required for successful staff mastery of job tasks related to claim reviews and special projects.</li> <li>Develops and implements operational guidelines for applicable payment policies and/or for other processes pertaining to the medical claim review function. Seeks organizational approval as indicated.</li> <li>Monitors the medical claim review tracking database for quality control. Compiles and analyzes data and prepares routine compliance reports.</li> <li>Performs other duties as required.</li> </ul> QUALIFICATIONS: <ul> <li>Excellent analytical and problem-solving skills</li> <li>Able to work independently as well as supervise others to meet stringent deadlines</li> <li>Strong attention to detail. Highly organized and capable of managing multiple projects.</li> <li>Proficient in Microsoft applications.</li> <li>Possess strong oral and written communication.</li> <li>Ability to work as a team in a high paced environment.</li> <li>Successful completion of Health Care Sanctions background check.</li> </ul> EDUCATION/EXPERIENCE <ul> <li>Current active, unrestrictive license to practice as a Registered Nurse (RN) in the State of Oklahoma.</li> <li>BSN preferred</li> <li>Minimum of five years combined employment in facility/provider health care settings or managed care organization.</li> <li>Minimum of two years supervisory experience.</li> <li>Prefer strong clinical related background and case review experience focused in healthcare fraud, waste and abuse. </li> <li>Require experience or familiarity with state and federal regulations governing healthcare coding, billing and claims processing. Recognized healthcare coding certification (CPC, AHIMA, etc.) preferred.</li> </ul> CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin <h2 id="otherDetailsHeader">Other details</h2> <ul> <li> Job Family Commercial </li> <li> Pay Type Salary </li> </ul> <a href="#"> Apply Now </a>

Medical Management - Supervisor Medical Review 145-4005

<h1>Quality Improvement - QI Stars Specialist_195-2016</h1> Tulsa, OK, USA Req #751 Friday, March 21, 2025 JOB SUMMARY: The Quality Improvement Stars Specialist is an integral part of the team, focusing on enhancing the performance of quality programs. This role requires a proactive individual who is adept at working collaboratively with provider groups and multidisciplinary teams with minimal oversight to ensure adherence to deadlines and compliance with regulatory requirements. The specialist will play a pivotal role in the analysis, development, and implementation of strategies aimed at improving Star Ratings. Included in this is the responsibility for managing and analyzing data from various surveys to drive process improvements and enhance the quality of care for our members. KEY RESPONSIBILITIES: <ul> <li>Monitor and analyze Star Ratings performance metrics to identify areas for improvement. </li> </ul> <ul> <li>Develop and maintain detailed reports on Star Ratings performance, trends, and forecasts. </li> </ul> <ul> <li>Plans, organizes, executes, and finishes assigned projects associated with program scope. </li> </ul> <ul> <li>Complies data and prepares reports for other program work related to State, Federal, and Accreditation requirements. </li> </ul> <ul> <li>Develop and maintain strong relationships with provider groups to foster collaboration and engagement in improving quality measures and patient outcomes. </li> </ul> <ul> <li>Coordinate the administration of CAHPS, QHP, and HOS surveys, ensuring timely and accurate data collection and submission. </li> </ul> <ul> <li>Monitor survey processes to maintain high response rates and data integrity. </li> </ul> <ul> <li>Analyze survey data to identify trends, strengths, and areas for improvement. </li> </ul> <ul> <li>Generate reports and dashboards to present findings to stakeholders. </li> </ul> <ul> <li>Present findings to senior management and stakeholders, providing actionable recommendations. </li> </ul> <ul> <li>Provide training and support to provider groups on best practices for achieving high Star Ratings. </li> </ul> <ul> <li>Supports the overall department goals and objectives, including back-up support for various departmental functions. </li> </ul> <ul> <li>Evaluate the effectiveness of quality improvement initiatives and make necessary adjustments. </li> </ul> <ul> <li>Collaborate with cross-functional teams to develop and implement quality improvement initiatives based on survey results. </li> </ul> <ul> <li>Track and evaluate the effectiveness of implemented changes. </li> </ul> <ul> <li>Ensure compliance with all CMS regulations and guidelines related to Medicare Advantage Star Ratings. Keep abreast of changes in Stars Rating program and updates internal processes accordingly. </li> </ul> <ul> <li>Assists with staff orientation, training, and re-training on program work requirements as indicated. </li> </ul> <ul> <li>Perform other duties as assigned. </li> </ul> QUALIFICATIONS: <ul> <li>Minimum of 3-5 years of experience in healthcare quality improvement or a related role. </li> </ul> <ul> <li>Strong understanding of Medicare Advantage Star Ratings and CMS guidelines. </li> </ul> <ul> <li>Excellent analytical, organizational, and communication skills. </li> </ul> <ul> <li>Ability to work independently and as part of a team. </li> </ul> <ul> <li>Ability to manage multiple tasks simultaneously, work independently with minimal supervision, and meet stringent deadlines. </li> </ul> <ul> <li>Demonstrates strong organizational skills and is attentive to details. </li> </ul> <ul> <li>Possess strong oral and written communication skills. </li> </ul> <ul> <li>Strong familiarity with managed care and healthcare terminology. </li> </ul> <ul> <li>Successful completion of Health Care Sanctions background check. </li> </ul> EDUCATION/EXPERIENCE: <ul> <li>(Preferred) Bachelor’s degree in healthcare administration, Public Health, Statistics, or a related field. </li> </ul> <ul> <li>Associates degree and/ or 3 years of experience in quality, benefit plans, claims, customer services, quality improvement, medical management, or similar healthcare operations. </li> </ul> CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin <h2 id="otherDetailsHeader">Other details</h2> <ul> <li> Job Family Commercial </li> <li> Pay Type Salary </li> </ul> <a href="#"> Apply Now </a>

Quality Improvement - QI Stars Specialist_195-2016

<h1>Medical Management - Concurrent Review Nurse- RN 145-2006</h1> Tulsa, OK, USA Req #775 Tuesday, March 18, 2025 JOB SUMMARY: Responsible for clinical review of utilization requests and assessment and implementation of potential coordination of care opportunities for overall membership, institutionalized populations, high risk members, and other members identified with at risk or high utilization needs. Functions as an active team member of the Concurrent Review Team. KEY RESPONSIBILITIES: <ul> <li>Performs utilization review of inpatient, post-acute, outpatient and ancillary services.</li> <li>Determines medical necessity and appropriateness of services using clinical review criteria.</li> <li>Accurately documents all review determinations and contacts providers and members according to established timeframes.</li> <li>Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director.</li> <li>Appropriately identifies and refers quality issues to Medical Management leadership.</li> <li>Appropriately identifies potential cases for Care Management programs.</li> <li>Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum.</li> <li>Performs accurate data entry.</li> <li>Communicates appropriate information to other staff members as necessary/required.</li> <li>Participates in continuing education initiatives.</li> <li>Collaborates with other departments as needed.</li> <li>Performs other duties as assigned.</li> </ul> QUALIFICATIONS: <ul> <li>Knowledge of managed care and associated group benefit plans.</li> <li>Possess strong oral and written communication skills.</li> <li>Ability to reason logically and to use good judgment when interpreting materials or situations.</li> <li>Knowledge of community- based resources.</li> <li>Must have excellent organizational skills and be able to perform multiple tasks.</li> <li>Proficient in Microsoft applications.</li> <li>Excellent time management and documentation skills.</li> <li>Successful completion of Health Care Sanctions background check.</li> </ul> EDUCATION/EXPERIENCE: <ul> <li>Graduation from accredited School of Nursing.</li> <li>Current, active, unrestricted license to practice as a Registered Nurse in the State of Oklahoma.</li> <li>Three years of acute care experience preferred.</li> <li>Two years of experience working with population health preferred.</li> <li>Previous discharge planning or case management experience preferred.</li> <li>Managed care experience a plus.</li> </ul> CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin <h2 id="otherDetailsHeader">Other details</h2> <ul> <li> Job Family Commercial </li> <li> Pay Type Salary </li> </ul> <a href="#"> Apply Now </a>

10 CommunityCare Jobs