Teams at Community Health Group

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.