CareSource

Customer Support

• Lead and direct their team to ensure goals, regulatory, compliance, and department standards are met
• Conduct regularly scheduled coaching conversations
• Properly document coaching and development conversations in HR system
• Complete performance appraisals
• Conduct monthly team meetings and huddles
• Analyze and leverage data to make recommendations and decisions
• Monitor key operational performance indicators
• Identify processes, tools, systems, and behaviors that cause negative impact on efficiency
• Build positive relationships and interactions with internal peers and leaders
• Promote positive change management
• Facilitate timely resolution of tasks requiring deadlines
• Implement, enforce, and support company policies and procedures
• Monitor and evaluate calls for quality, compliance, efficiency, and customer satisfaction purposes
• Conduct interviews and evaluate candidates for hiring purposes

Team Lead, Customer Care

Business Analyst

• Reviewing and analyzing the effectiveness and efficiency of existing processes and systems, and participate in development of solutions to improve or further leverage these functions
• Perform cost-benefit and return on investment analyses for proposed initiatives to aid decision-making process as well as collect and analyze data in support of business case creation and realization
• Ensures operational effectiveness by assisting in strategic and business planning, including business, financial, and operational goals and objectives definition as well as feasibility studies
• Recognizes and proactively manages scope and expected benefits across the organization’s strategic initiatives and process improvements
• Takes a leading role in the operational readiness process by reviewing transitional activities and associated documentation for completion prior to initiative implementation, including operational reports, turnover documentation, departmental policies and procedures and job aids
• Takes a leading role in the review of reports and data for pattern identification, special cause variation identification, trend analysis, or other techniques; prepare and deliver summaries, recommendations, or alternatives of the analyzed information.
• Develop, document and perform testing and validation as needed
• Mentor Business Operations Analyst/Associates to achieve cross-functional capability with project execution and subject matter expertise
• Perform any other job duties as requested

Operations Business Analyst III

Reviewer

• Supports successful completion and submission of the MDS (Minimum Data Set) to MassHealth
• Examines MDS assessments prepared by clinicians to ensure completeness, accuracy and appropriate explanation of functional status and related clinical findings
• Provides feedback to Clinical Care Manager to facilitate optimal documentation and, where necessary, rating category assignment
• Supports the Proxy MDS Reviewer (LPN) in completing Proxy MDS submissions for members who cannot be reached for assessment
• Completes portions of the electronic MDS-HC form based on diagnoses/information gathered from record review
• Prepares printed MDS forms for data entry
• Conducts routine training sessions for new Care Management staff and relevant Clinical Care Manager to drive high quality, consistent MDS assessments
• Conducts reviews in a timely way in accordance with all timeliness and quality standards
• Provides clinical care to members via telehealth technologies (video, chat, etc.)

RN MDS Reviewer

Investigator

• Responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professionals, facilities, and members
• Research, gather, and analyze data to identify trends, patterns, aberrancies, and outliers in provider billing behavior
• Serve as a subject matter expert for other investigators
• Develop, coordinate and conduct strategic fact-driven investigative projects
• Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data
• Ensure quality outcomes for investigative team through auditing and oversight
• Use knowledge of coding guidelines to analyze complex provider claim submissions
• Prepare and conduct in-depth complex interviews relevant to investigative plan

SIU Investigator III, Health Plan Experience Required

Medical Reviewer

• Support most complex medical record audit programs
• Generate concise in-depth reporting and analysis to track performance
• Provide Provider Pre Pay production and progress reports
• Recommend process or procedure changes
• Demonstrate leadership ability
• Identify knowledge gaps and provide training opportunities
• Serve as a primary resource for provider escalation support
• Maintain a working knowledge of all state and federal laws, rules, and billing guidelines

Medical Coding Reviewer III, CPC, RHIT/RHIA Required

Community Manager

• Provide front line management and support to departmental leadership in care model development
• Supervise staff and maintain adherence to departmental expectations
• Oversee recruiting, hiring, onboarding, training, and ongoing support of the departmental team
• Conduct meetings to train, lead, and support staff in effective administration of CM program
• Prepare and utilize reports for monitoring and auditing systems and quality of services
• Assist in representing the unit at Departmental and Planning meetings as requested
• Ensure staffing policies and procedures are standardized and current
• Collaborate with internal resources to monitor service levels
• Participate in development of budget and ongoing monitoring of status
• Implement interventions to maintain quality and efficiency of services

Team Lead, Community Based Care Management

Data Scientist

• Designing and validating predictive models and machine learning models
• Create, maintain, and communicate an analytical plan for each project
• Mine and analyze large structured and unstructured datasets
• Develop visualizations that demonstrate the efficacy of developed algorithms
• Prepare code for operationalization of end-to-end model pipeline and deliverable for business consumption

Data Scientist II

Operations

• Engage with the enrollee in their homes and other community settings to establish an effective, complex care management relationship, while considering the cultural and linguistic needs of each member.
• 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, including but not limited to Comprehensive Assessment, MDS-HC (or successor) Functional Assessments, and Crisis and Risk Assessments.
• Engage enrollees in care plan development and implementation, providing routine updates as the enrollee’s status changes.
• Lead the interdisciplinary care team (ICT) and collaborate with peers both internal and external to the organization, to create holistic care plans that address medical and non-medical needs.
• Oversee enrollee utilization of long-term services and supports, ensuring appropriate systems are in place for enrollees to remain in the location of their choice.
• Assist members in accessing community resources, including housing, transportation, food assistance, and social services.
• Educate members about their benefits and available services under both Medicare and Medicaid.
• Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care.
• Promote healthy lifestyle choices and self-management strategies.
• Assist enrollees in preventative health strategies, including gap closure.
• Follow up with members after hospitalizations or significant health events to ensure continuity of care and prevent readmissions.
• Work closely with primary care physicians, specialists, and other healthcare providers to coordinate care and share relevant information.
• Coordinate with community-based organizations, other stakeholders/entities, state agencies, and other service providers to ensure coordination and avoid duplication of services.
• Advocate for the needs and preferences of enrollees within the healthcare system.
• Evaluate member satisfaction through open communication and monitoring of concerns or issues.
• Regular travel to conduct member, provider and community-based visits as required.
• Report abuse, neglect, or exploitation of older adults and adults with disabilities as a mandated reporter as required by State law.
• Adhere to NCQA and Care Management standards.
• Perform any other job related duties as requested.

Registered Nurse (RN), Clinical Care Manager

Manager

• Engage with the enrollee in their homes and other community settings
• Function as a liaison between healthcare providers, community resources, and enrollees
• Perform required assessments on a timely basis
• Lead the interdisciplinary care team (ICT)
• Oversee enrollee utilization of long-term services and supports
• Educate members about their benefits and available services

Behavioral Health Clinical Care Manager

• Provide monitoring, follow-up and clinical care management to dually-eligible enrollees with complex medical, behavioral and social care needs
• 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 both internal and external to the organization.
• 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.
• Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care.
• Follow up with members after hospitalizations or significant health events to ensure continuity of care and prevent readmissions.
• Report abuse, neglect, or exploitation of older adults and adults with disabilities as a mandated reporter.

Registered Nurse (RN) Clinical Care 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, providing routine updates as the enrollee’s status changes
• Lead the interdisciplinary care team (ICT) and collaborate with peers to create holistic care plans
• Advocate for the needs and preferences of enrollees within the healthcare system
• Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care
• Follow up with members after hospitalizations or significant health events

Scrum Master

• Guide and coach the Scrum Team and organization on how to use Agile/Scrum practices and values
• Provide support to the team using a servant leadership style and lead by example
• Responsible to hold team accountable to the tenants of agile and working agreements including the use of appropriate tools, standards and best practices
• Promote and demonstrate core agile principles of collaboration, prioritization, team accountability and visibility
• Empower the team to self-organize around achievement of their commitments
• Identify and remove any impediments and distractions that interfere with the team’s ability to deliver against their commitments
• Recommend improvements and assist in changes to best practice where appropriate
• Assist the team in tracking and communicating team progress and metrics
• Facilitate and enable an environment of collaboration and creativity
• Assess the Agile/Scrum maturity of the team and organization
• Coach the team to higher levels of maturity, at a pace that is sustainable and comfortable for the team and organization
• Build a trusting and safe environment where problems can be raised without fear of blame, retribution, or being judged
• Facilitate getting the work done without coercion, assigning, or dictating the work
• Facilitate discussion, decision making, and conflict resolution
• Assist with internal and external communication, improving transparency, and radiating information for better visibility
• Support and educate the Product Owner, especially with respect to refining and managing the product backlog

Scrum Master II

Clinical Psychologist

• Provides Behavioral Health coverage determination for utilization management
• Assumes responsibility for the overall safety of patients with a BH diagnosis
• Serves as the clinical lead in developing and implementing evidenced based clinical policies and practices
• Participates in regulatory/accreditation reviews

Medical Director

• Assume responsibility for the overall safety of patients with a BH diagnosis, with a special focus on safe prescribing
• Serve as the clinical lead in developing and implementing evidenced-based clinical policies and practices
• Participate in regulatory/accreditation reviews
• Assume key role in quality improvement initiatives, case management activities and member safety activities
• BH coverage determination for utilization management to ensure members receive appropriate and medically necessary care in the most cost-effective setting
• Oversight and quality improvement activities associated with case management activities
• Provide guidance to BH orientation and network development/recruitment in conjunction with provider relations
• Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate
• Represent CareSource as the primary clinical liaison to members, providers and State agencies
• Support of regulatory and accreditation functions and compliance for all programs
• Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards
• Participate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives
• Collaborate with market/product leaders to help define market strategy
• Community collaborative participation
• Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
• Provide cross-coverage for other Medical Directors and/or markets, as needed
• Support staff by providing training, clinical consultation, and clinical case review for members including Medical Advisement meetings
• Perform any other job duties as requested

Behavioral Health Medical Director

• 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, including but not limited to Comprehensive Assessment, MDS-HC (or successor) Functional Assessments, and Crisis and Risk Assessments
• Lead the interdisciplinary care team (ICT) and collaborate with peers both internal and external to the organization, to create holistic care plans that address medical and non-medical needs
• Advocate for the needs and preferences of enrollees within the healthcare system
• Follow up with members after hospitalizations or significant health events to ensure continuity of care and prevent readmissions
• Assist enrollees in preventative health strategies, including gap closure