CareSource

Public Relations

• Leverage advanced media relations expertise to protect the CareSource brand
• Drive brand awareness and positioning across a broad range of platforms
• Lead the development of strategic communications plans
• Proactively identify and lead high-impact media relations opportunities
• Develop campaign KPIs in concert with key internal stakeholders
• Measure and report for continuous optimization
• Manage agency relationships
• Lead the development and implementation of comprehensive media strategies for crisis communications
• Act as a subject matter expert for internal and external communication initiatives
• Oversee the creation of high-value external materials
• Drive content strategy and development for media and external communications
• Monitor industry trends, media coverage, and competitors
• Provide advanced guidance on media training for key spokespeople
• Lead cross-functional project teams

Media Relations Specialist IV

Manager

• Engage with the enrollee in their homes and other community settings to establish an effective, complex care management relationship
• Function as a liaison between healthcare providers, community resources, and enrollees to ensure seamless communication and care transitions
• Perform required assessments on a timely basis
• Engage enrollees in care plan development and implementation
• Lead the interdisciplinary care team (ICT) and collaborate with peers
• Oversee enrollee utilization of long-term services and supports
• Assist members in accessing community resources
• Educate members about their benefits and available services under both Medicare and Medicaid
• Assist enrollees in preventative health strategies
• Follow up with members after hospitalizations or significant health events
• Work closely with primary care physicians, specialists, and other healthcare providers

Registered Nurse (RN) Clinical Care Manager

Data Engineer

• Key contributor for data stewardship workgroups and teams in data management and governance activities
• Be a champion or ambassador of metadata and data quality practices across the organization – leading lunch ‘n’ learn sessions, knowledge sharing sessions, etc.
• Gain an understanding of the stakeholder’s business culture and priorities, and the need for different modeling techniques when eliciting definitions and data quality requirements
• Accountable and responsible for the engineering success of specific data governance engineering programs (e.g. Metadata and Cataloging Program, Data Quality Program)
• Perform analysis and research to support and/or develop glossary definitions, policies, programs, standards, guidelines and workflows
• Lead the development and maintenance of metadata catalogs
• Identify and quantify data related pain points within the organization and assist in the development of remediation plans
• Collaborate with SMEs to develop business rules that measure and assure data quality; facilitating discussions with end users and data modelers
• Lead efforts to quantify and qualify reported data quality issues; develop and report program metrics to demonstrate progress and compliance
• Sets objectives for own job with the understanding of how output would affect and impact other job areas related to own job
• Contributes and provides input to the development of operational area goals within the context of own job area
• Work consists of tasks that are typically not routine, works independently and applies discretion within established operational boundaries and procedures
• Work direction is only provided for new areas of work or unique assignments
• Problems and issues faced are vague, and require reasoning and analysis to address problems and issues
• Updates and/or modifies work methods based on past experiences, and identifies solutions to problems by recognizing similarities through data trends
• Has higher autonomy to arrive at solutions to non-routine problems within established operational boundaries and procedures
• Uses personal experiences, makes reasonable judgment calls, and may call on other resources where necessary to identify solutions
• Perform any other job duties as requested

Data Engineer III

Medical Billing and Coding

• Responsible for making claim payments decisions on a wide variety of claims within department standards
• Responsible for researching, analyzing, and making payment decisions on moderately complicated claims based on medical coding guidelines and policies
• Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business
• Acts as a technical resource to new associates by reviewing claims, training staff, responding to claim questions
• Responsible for identifying and implementing process improvements and referring system enhancement ideas to manager
• Collaborates with internal departments to facilitate claim processing and to come to appropriate claim resolutions
• Responds to claim questions and concerns
• Prepares claims for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as needed
• Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims
• Responsible for identifying systemic claim problems/concerns and reporting them to management
• Responsible for supporting provider pre-pay and post-pay teams with coding reviews and clinical documentation reviews
• Provide support for provider appeals to denied claims

Program Integrity Medical Coding Reviewer II, CPC, RHIT, RHIA

Financial Planning and Analysis

• Provide timely, accurate comprehensive and transparent financial reporting
• Responsible for input and review of market finance IBNR models
• Understand reimbursement methodologies impacting market products
• Support monthly close process by providing journal entries, accruals and supporting analysis
• Responsible for coordinating with market/work stream leaders to identify, implement and measure QAI initiatives to exceed targets
• Support Market’s APM, VBR, ACO, and other delegated arrangement strategies
• Coordinate/liaison revenue maximization efforts between teams and providers
• Support the annual budget and monthly/quarterly forecasting process
• Provide insight into the risk sensitivity associated with current and future business drivers

Director, Finance - Market

Analyst

• Providing support on special projects, initiatives, and specific activities which will vary by assignment.
• Collaborating with CareSource teams on various assignments.
• Utilizing knowledge of relational databases and claims operations for data analysis and reporting.
• Engaging in training and mentorship programs to enhance skills and career growth.

Internship - Claims Encounters Analyst

Software Engineer

• Analyze, design, code and test software through the production lifecycle
• Run and monitor software performance tests
• Assist in software deployment as required
• Liaise with network administrators and software engineers
• Perform technical code reviews of peers
• Maintain an understanding of software development life cycle (SDLC)

Application Developer II

Director

• Assists the VP of Social Work and Community Health Services to assure that appropriate, high-quality clinical management is provided to all ESH members in accordance with relevant regulations.
• Provides direct managerial oversight and supervision to the social service staff in the MLTC Program.
• Oversees the Medicaid eligibility department, addresses and resolves unpaid Medicaid claims and Medicaid surplus payments issues.
• Assures Medicaid applications, renewals, deferrals and conversions are completed on time.
• Responsible for establishing appropriate, New York State code compliant, personnel policies and procedures including those relating to hiring practices, health status examination, and periodic evaluation.
• Orientation and in-service education.
• Participates in hiring, retention, evaluating, disciplining and termination of staff.
• Ensures compliance, consistent with health rules of the New York State Department of Health.
• Performs clinical oversight of contracted agency social workers.
• Participates in developing standards which insure safe and therapeutically effective service to clients and families.
• Oversees the clinical supervision of staff to assure standards of care are met and/or assures that appropriate supervision is provided.
• Participates in the planning, development, implementation and evaluation of staff orientation and in-service Education programs.
• Represents Program at Professional Meetings.
• Provides direct supervision of clinical staff and eligibility specialists.
• Prepares for the participation in certification visits from Regulatory/Accrediting bodies.
• Represents Program to community.
• Reviews weekly claims report and report findings with the VP of Social Work & Community Health Services or designee.
• Monitors clinical quality (productivity Data collection, assessment, care planning, documentation) and provide case consultation on complex cases (abuse/neglect, suicidality, housing and benefits crises).

Assistant Director of Social Services

• Collaborates with members of an inter-disciplinary care team (ICT)
• Facilitates communication, coordinates care and service of the member through assessments
• Engage the member and their natural support system through strength-based assessments
• Develop a person-centered individualized care plan (ICP) in collaboration with the ICT
• Identify and manage barriers to achievement of care plan goals
• Act as a liaison to social service agencies, community-based organizations and support groups
• Educate the member/natural supports about community resources, insurance benefits
• Verify eligibility, previous enrollment history, demographics and current health status of each member
• Complete psychosocial and behavioral assessments by gathering information from the member and stakeholders
• Assess for clinical risk factors that could result in readmission

Care Manager – Post Partum

• Responsible for providing care coordination including in-home assessment, planning, facilitation, advocacy and authorization of covered plan services to meet the member's health needs
• Ensures consistent care along the entire health care continuum by assessing and closely monitoring members’ needs and status
• Authorizes covered services and coordinates care regardless of payer
• Collaborates and communicates with member/family/caregivers, primary care practitioners, and the interdisciplinary team
• Works with member/family to maintain the most independent living situation possible
• Assesses, plans and provides continuous care management across all venues of care, including hospital, sub-acute, long-term and home settings
• Regularly assesses members for ongoing eligibility for services based on the specific plan’s eligibility criteria
• Performs home visits as required to assess members’ living situation, cultural influences, functional and cognitive needs
• Collaborates with the primary care physician and Inter-Disciplinary Team (IDT) to develop the Patient Centered Service Plan for the member
• Documents care management/coordination according to company policy to the specific plan the member is enrolled in
• Develops efficient plans of care, authorizing only needed services at the most appropriate levels, utilizing network providers and ensuring that services are based on members’ needs

Registered Nurse, Care Manager

• Provides care coordination including in-home assessment, planning, facilitation, advocacy and authorization of covered plan services to meet the member's health needs
• Ensures consistent care along the entire health care continuum by assessing and closely monitoring members’ needs and status
• Authorizes covered services and coordinates care regardless of payer
• Collaborates and communicates with member/family/caregivers, primary care practitioners, and the interdisciplinary team
• Works with member/family to maintain the most independent living situation possible
• Assesses, plans and provides continuous care management across all venues of care, including hospital, sub-acute, long-term and home settings
• Regularly assesses members for ongoing eligibility for services based on the specific plan’s eligibility criteria
• Performs home visits as required to assess members’ living situation, cultural influences, functional and cognitive needs
• Collaborates with the primary care physician and Inter-Disciplinary Team (IDT) to develop the Patient Centered Service Plan for the member
• Ensures appropriate, safe plan for members’ discharge from their plan
• Identifies same day grievances, investigates and documents accordingly
• Documents any grievance according to plan policy
• Identifies and presents members with complex care management needs or in difficult to manage situations at Intensive Care management meetings (ICM)
• Responds to members’ requests in the designated timeframes and completes Initial Adverse Determinations (IAD) as indicated
• Identifies members requiring Care Management Review (CMR), evaluates documentation provided by the IDT including hospital or nursing home discharges planners, and formulates appropriate plan of care
• Documents care management/coordination according to company policy to the specific plan the member is enrolled in, which may include monthly telephonic and in person recertification notes
• Develops efficient plans of care, authorizing only needed services at the most appropriate levels, utilizing network providers and ensuring that services are based on members’ needs
• Perform any other job related duties as requested

Registered Nurse (RN) Care Manager

• Provide financial oversight, leadership and support to the market/corporate
• Ensure comprehensive financial reporting including operating statements and key business reports
• Coordinate annual budget and financial forecasting process
• Support strategic planning process with long term projections
• Oversee and drive the allocation process aligning strategies with organizational goals
• Collaborate in HCQI process ensuring alignment with organizational goals
• Participate in cross-functional discussions for administrative efficiencies
• Support independent financial accounting audits and ensure compliance
• Perform ad hoc and trending analysis as requested
• Manage departmental staff and expense budget

Director of Finance, Accounting

• Collaborates with members of an inter-disciplinary care team to improve quality and meet the needs of the individual
• Facilitates communication, coordinates care and service of the member through assessments
• Develop and regularly update a person-centered individualized care plan in collaboration with the ICT
• Identify and manage barriers to achievement of care plan goals
• Educate the member/natural supports about treatment options, community resources, insurance benefits, etc.
• Document care coordination activities and member response in a timely manner according to standards of practice and CareSource policies

Care Manager – Transitions of Care

• Responsible for end-to-end acquisition and implementation of all defined clinical data sources
• Gather and assess clinical data business requirements for current and new market implementations
• Maintain group focus and manage group dynamics in facilitating requirements gathering and review sessions
• Serve as a bridge between healthcare providers, vendors and IT teams
• Lead and manage external relationships with assigned data aggregators and vendors
• Identify data trends, create reports and present findings concisely
• Coordinate with procurement team to submit and maintain contract requests for clinical data vendors

Clinical Data Acquisition Analyst

• Oversee all behavioral health utilization management activities ensuring consistency of services and achievement of utilization targets
• Assist in coordination and management of the pre-determination process of behavioral health services
• Ensure the consistent application of criteria for authorization decision
• Interact with providers and staff to manage benefits aligned with state-based regulations
• Review and revise workflows to maximize efficiencies
• Monitor productivity and utilization trends
• Oversee CQI activities and ensure audits and staff feedback occur at regular intervals
• Regularly report all utilization management regulatory requirements
• Ensure compliance with and reporting of all regulatory requirements
• Maintain all behavioral health utilization management reporting and trend data
• Analyze under and over utilization information for impact on member quality of care and outcomes
• Develop, maintain and update all departmental policies and procedures