Jobs at Community Health Group

Provide Medicare member support and care coordination through home visits, phone outreach, scheduling, interpreter/transportation/prior authorization facilitation, documentation, grievance referral, and community resource linkage. Participate in on-call rotations and complete welcome calls.

Support Appeals Manager by investigating and resolving member grievances and appeals per Medicare/Medi‑Cal regulations. Use QNXT and Innovare to gather eligibility, claims, and case data, communicate findings, prepare decision letters, escalate quality‑of‑care issues, compile compliance reports, and liaise with providers and internal departments to meet timeliness and regulatory requirements.

Lead compliance activities and serve as the SIU investigator: investigate potential fraud, gather evidence, prepare reports, liaise with law enforcement and regulators, support privacy incident investigations, coordinate CMS/DMHC/DHCS audits, maintain compliance policies, deliver training, and track FWA program performance.

Conduct internal audits across managed care departments (UM, CM, MS, Pharmacy, ECM/CS, G&A) to ensure compliance with federal/state regulations and policies, document findings, issue CAPs, follow up on corrective actions, recommend training, and support external audit preparation.

Perform community outreach and education about Medicare and Medi-Cal managed care; enroll eligible individuals into plans; conduct presentations, provider surveys, and health fair participation; collaborate with internal teams and attend trainings to ensure compliance with federal and state regulations.

Supervise case management activities to resolve Medicare member concerns, coordinate care and services (including home visits), document interactions, meet phone benchmarks, refer grievances, assist with transfers and billing issues, and partner with community organizations to address members' medical and social needs.

Provide utilization and case management for members, review clinical documentation and medical necessity, coordinate care and transitions, collaborate with providers, refer complex cases, support quality improvement, and ensure regulatory compliance.

Provide customer-focused case management for Medicare members: conduct home visits, coordinate medical, behavioral and social services, resolve member concerns, document interactions, assist with transfers and urgent care coordination, and work with community resources to address non-medical needs. Participate in on-call rotation and complete welcome calls, ensuring compliance with Medicare and state regulations.

Provide oversight of care coordination for assigned caseloads, conduct home visits, monitor inpatient/outpatient services, document in CHGNet and QNXT, facilitate transitions of care, ensure treatment plan compliance, assist providers with chronic and disease-specific management, participate in quality improvement, and collaborate with internal and external health care teams.