CommuniCare Health Services

Billing Specialist

• Reviewing cases for Part B therapy appeals
• Logging therapy appeal cases in Axis
• Submitting therapy appeals to the appropriate payer via their web portals (IE: Availity, Buckeye, Caresource, etc.)
• Submitting corrected claims to various Managed Care payers for missing authorization
• Following up on appeals with auditing contractors and payers
• Submitting write offs on accounts deemed uncollectible
• Notating on accounts in PCC in compliance with the dashboard collection policy
• Account research as it pertains to cash postings and adjustments
• Monitoring the ADR payers
• Ensuring proper logging and statusing of all ADRs and therapy appeals in Axis
• Assisting with report set up to ensure accuracy of data
• Set up for electronic eMDR notification in NPPES/Waystar for Medicare pre and post pay ADRs
• Assisting with electronic notification set up for other various ADRs
• Calculating at risk amounts for partially favorable ADRs
• Required knowledge of updating/changing PDPM/RUG scores in PCC to obtain difference, and knowing what dates of service to change, and appropriately changing back
• Other duties as assigned

ADR Billing Specialist

Manager

• Coordinate and manage collaborative care services for residents.
• Work closely with psychiatric providers and licensed social workers to ensure seamless care delivery.
• Monitor and support residents’ progress in achieving mental health goals.
• Maintain accurate records using electronic medical records (EMR) systems and provide feedback to the care team.

Behavioral Health Care Manager

Medical Director

• Evaluate facility compliance to clinical policy, procedure, and care
• Visit facilities weekly for intervention, audit and training
• Train new nursing management
• Monitor readiness for State Survey and assist during surveys
• Aid in the Plan of Correction process

Registered Nurse, Regional Director of Clinical Operations

• Oversee and coordinate the care of assigned ISNP members, ensuring they receive timely and appropriate care as dictated by the SNP Model of Care.
• Perform initial, annual, transition of care (TOC) and change in condition health risk assessments (HRA) for ISNP care managed caseload.
• Formulate and implement a member centric holistic care plan that addresses identified needs by assessing the member/representative/family needs, issues, resources and care goals; determining and educating on the choices available to the individual member.
• Collaborate with the interdisciplinary team (ICT) which may include Medical Director, PCP, nurse practitioners/physician assistants, pharmacy, dietary, social workers, other clinical and non-clinical disciplines, facility staff, member representatives and family to establish, revise and continuously evaluate the member centric care plan.

Health Plan Care Manager, RN / LSW

Human Resources

• Focused, professional recruitment efforts that will attract the right people for the right jobs.
• Consistent, positive engagement efforts that will create a team of employees who reflect CommuniCare’s core values and know they are respected members of the CommuniCare family.
• Ensuring regulatory legal compliance for all relevant federal, state, and local laws and regulations as they apply to all team members.
• Recognition that reduces turnover to a minimum.
• Supporting managers to enable them to focus on their people as the agents for the special care we give.

Mobile Employee Life Cycle Manager

Therapist

• Provide psychotherapy, group therapy, and collaborative care management to residents in need.
• Deliver individual and group psychotherapy sessions tailored to the needs of residents.
• Facilitate collaborative care management by coordinating with psychiatrists, primary care providers, and other team members.
• Address the mental health needs of residents with chronic severe mental illness, substance use disorders, depression, and major neurocognitive disorders.
• Develop and implement therapeutic interventions using evidence-based modalities.
• Maintain detailed and accurate clinical documentation in an electronic medical records (EMR) system.

ADR Billing Specialist

Behavioral Health Care Manager

Registered Nurse, Regional Director of Clinical Operations

Health Plan Care Manager, RN / LSW

Mobile Employee Life Cycle Manager

Therapist, Behavioral Health Care Manager (LSW, LISW)