CareSource

SDET

• Responsible for day-to-day activities surrounding the knowledge and insight around testing of medical benefits, provider reimbursement, letters, claims workflow and clinical editing
• Guide and direct successful completion of daily tasks
• Responsible for onboarding, training and development of staff
• Prioritize all work, requests and activities
• Escalate any area of significant resource contention along with recommendation for resolution
• Track issues and status to ensure proper follow-up, coordination with business area and provide solutions
• Update project that configuration is involved with and coordinate any needed changes with manager
• Provide management with ticket dashboards
• Identify root cause of issues and appropriate pro-active resolution to reduce tickets in the future
• Perform any other job duties as requested

Team Lead, Configuration Testing – SDET, Facets, AI, RPA

ServiceNow

• Develop the strategic vision for an IT product
• Work closely with the Scrum team to maintain focus on goals, alignment with business needs and urgent matters
• Motivate the Scrum team by leading with purpose and providing clear goals and direction
• Own prioritization of the product backlog including definition of user stories and acceptance criteria
• Prioritize IT work in accordance with strategic vision, company goals and industry trends
• Ensure acceptance criteria for UAT is set
• Keep customers or users apprised of status and getting their feedback
• Communicate effectively to ensure internal stakeholder expectations are set correctly
• Participate in Sprint Planning, Sprint Retrospectives, and Sprint Demos
• Understand, use, and champion agile best practices
• Partner with stakeholders to understand needs across the enterprise
• Work closely with other Product Owners to ensure product roadmap priorities are being met
• Work closely with other Product Owners to identify dependencies, overlap, and integration opportunities

Scrum Product Owner – ADO, ServiceNow Queries

Security Engineer

• Measure, monitor, and report on information security risks
• Review and report on vendor/third party risk to support vendor risk management activities
• Engage staff and/or vendors to develop information security risk mitigation plans to address risks identified in Vendor risk reviews
• Monitor and report on information security risk mitigation plans to ensure timely execution
• Engage employees in the management of information security risk and ensure they are aware of their accountabilities with regard to information security risk management
• Regularly assess and report to management any exceptions to information risk management policies, procedures and limits
• Engage with the Enterprise Risk Management office to ensure information risk management policies, procedures and limits are aligned with Enterprise Risk Management policies and guidance
• Contribute and provide input to the development of operational department goals
• Acts as technical expert in functional domain
• Recommends technical advancements to improve CareSource customer and partner experiences
• Perform any other job related instructions as requested

Information Security GRC Analyst III – Third Party Risk

Systems Engineer

• Lead research and analysis to identify systems impacted by requirements
• Collaborate with BI team or BI developers to automate metric reporting and dashboards
• Recognize inconsistencies and gaps in complex business processes
• Author clear agile stories and features for translating business needs and technical requirements
• Serve as a liaison between technical teams and users, stakeholders
• Assist QA in preparation of test scenarios and test data

Systems Analyst III

Customer Support

• The Team Lead, Customer Care is responsible for leading and directing their team to ensure goals, regulatory, compliance, and department standards are met.
• Conduct regularly scheduled coaching conversations; listening and providing feedback for improved performance, and when applicable, create performance improvement plans.
• Monitor key operational performance indicators on a daily, weekly, monthly basis to identify key trends and develop action plans that address opportunities.
• Build positive relationships and interactions with internal peers, leaders, and cross functional partners through strong follow through and communication.

Team Lead, Customer Care

Director

• Lead the development of the overall Marketplace Program Strategy
• Work with Enterprise functional areas to align program strategy and goals
• Execute enterprise strategies to improve market/business performance
• Establish relationships with Enterprise functional business leaders
• Develop KPIs and metrics supporting the Marketplace Enterprise strategy
• Evaluate administrative spend and identify cost-saving initiatives
• Ensure performance improvements are implemented
• Accountable for hiring, training, and motivating collaboration
• Develop budget for area of responsibility

Senior Director, Marketplace Performance and Strategy – Duals Plans, Medical Equipment

• Assist UM leadership in leading and managing all functions within behavioral health management
• Collaborate with market and enterprise leaders to support development and knowledge transfer for Behavioral Health UM
• Monitor effective use of prior authorizations, policies, and benefits
• Facilitate and promote problem identification, analysis, and resolution
• Ensure Behavioral Health UM programs and operational processes are properly developed and aligned to the organization’s strategic goals
• Identify and report risk management issues for the department and CareSource as a whole

Associate Director, Utilization Management – Behavioral Health

Solutions Engineer

• Lead the design and analysis for cohesive, cloud focused, solution architectures
• Develop comprehensive plans to migrate on-prem applications to the cloud using cloud-native technologies
• Evaluate new cloud technologies and recommend adoption strategies that align with strategic goals
• Oversee technical design of complex cloud systems, ensuring they are safe, scalable, and industry compliant
• Develop and document system architectures focusing on containerization, cloud-native technologies, and microservices
• Create strategies for optimizing cloud resource utilization and cost management
• Develop and enforce architecture standards and best practices
• Document all solution architecture work, focusing on system integrations
• Create detailed technical specifications, including data models, API designs, integration points, and security protocols
• Support critical development phases, including code reviews and troubleshooting
• Design and implement cloud native proof-of-concepts (POCs) to evaluate new technologies
• Lead integration of third-party services and tools
• Lead design and implementation of cloud and hybrid security architectures
• Translate business requirements into technical solutions
• Facilitate technical discussions and workshops
• Act as a consultant on a range of technologies and platforms
• Build technology roadmaps for best-in-class services
• Architect and implement solutions using cloud platforms (Azure, AWS, GCP)
• Ensure cloud solutions comply with security, regulatory, and organizational policies
• Identify and address technical debt within existing systems
• Collaborate with the infrastructure team for on-premises and cloud-based needs

Solution Architect III

Risk

• Collaborating with leadership to develop the Data Management and Governance programs
• Drafting data management policies, programs, standards and guidelines
• Leading Data Domain Council meetings
• Mentoring and coaching Data Governance Analysts and Data Stewards
• Leading data stewardship workgroups and teams in data management and governance activities
• Maintaining the group focus; leading discussion toward stated goals and managing group dynamics
• Gaining an understanding of the stakeholder’s business culture and priorities
• Accountable and responsible for the success of specific data management programs
• Performing analysis and research to support and/or develop glossary definitions, policies, programs, standards, guidelines and workflows
• Developing and reporting program metrics to demonstrate progress and compliance
• Leading the development and maintenance of meta-data catalogs
• Identifying and quantifying data-related pain points within the organization
• Collaborating with SMEs to develop business rules that measure and assure data quality
• Facilitating discussions between end users and data modelers
• Responsible for interacting with business and IT resources, and management to coordinate and monitor activities needed to initiate, run and conclude data management/data governance (DM/DG)

Data Governance Analyst III

QA Engineer

• Analyzing healthcare utilization to identify patterns, variation, and outliers
• Identify, quantify and model opportunities to reduce medical costs
• Evaluate the effectiveness of medical cost reduction initiatives
• Complete analytic process from start to finish and provide recommendations
• Develop tools to efficiently compare market performance
• Support the intake, prioritization and coordinated execution of ad-hoc analytics requests

Medical Economics Analyst II

Analyst

• Serve as a liaison for Value Added Services/Benefits, member incentives and rewards programs
• Supports member and community advisory committee meetings, including in rural communities if applicable
• Supports the implementation and data analysis of member engagement and retention strategies
• Facilitate and manage workgroups to collect and document retention initiatives
• Evaluate and trend complaint data and recommend and implement solutions to strengthen the program and mitigate member disenrollment

Member Engagement Analyst III

Compliance

• The Associate Director, Compliance is responsible for establishing a baseline of compliance risk
• Identifying areas of potential exposure
• Developing and aligning compliance risk management strategies with CareSource goals and objectives
• Executing the compliance program ensuring effectiveness
• Serves as the program compliance leader for an assigned Medicaid, Medicare, or Marketplace CareSource program
• Building and maintaining a strong relationship and goodwill with the relevant regulatory entity
• Assist the Program or Regional Compliance Officer with the implementation of an effective compliance program
• Oversee all assigned program compliance activities performed and tracked by compliance staff
• Build and maintain strong partnerships with business units
• Remain current and help drive interpretation and implementation of federal/state laws and regulations regarding Medicaid, Medicare and Marketplace requirements
• Provide feedback to Compliance leadership concerning key risks in assigned program
• Manage and drive effective usage of compliance tools and data for the compliance tracking systems
• Track and trend issues to identify compliance risk and performance improvement opportunities
• Assist with regulatory audits

Associate Director, Compliance, Managed Care

Medical Billing and Coding

• Generates comprehensive and concise in-depth reporting and analysis to track performance related to the Pre-Pay and Post-Paid Processes
• Provides Provider Pre Pay production and progress reports and coordinates with management and team on recommendation for further actions and/or resolutions
• Recommends process or procedure changes while building strong relationships with cross departmental teams
• Demonstrates leadership ability, including mentoring Program Integrity Claims Analysts
• Identifies knowledge gaps and provides training opportunities to team members
• Coordinates the training of new and existing claims analyst staff
• Identifies and assists in correction of organizational workflow and process inefficiencies
• Serves as the primary resource for provider pre-pay team
• Analyzes complex provider claims submissions using medical coding guidelines and policies
• Researches, comprehends and interprets various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines

PI Medical Coding Reviewer III, CPC, RHIT, RHIA required

Community Manager

• Engage with member in a variety of community-based settings to establish an effective, care coordination relationship, while considering the cultural and linguistic needs of each member.
• Conduct comprehensive assessments to determine the needs of members eligible for community-based waiver services.
• Develop individualized service plans that outline the necessary supports and services, ensuring they align with the individual’s preferences and goals.
• Serve as the primary point of contact for members and their families, coordinating care across multiple providers and services, including healthcare, social services, and community resources.
• Facilitate access to necessary services such as home health care, personal care assistance, transportation, and other community-based supports.
• Regularly monitor the implementation of service plans to ensure that services are being delivered effectively and that individual needs are being met.
• Conduct follow-up assessments to evaluate the effectiveness of services and make adjustments to person-centered care plans as needed.
• Advocate for the rights and needs of members receiving waiver services, ensuring they have access to the full range of benefits and supports available to them.
• Empower members and their families/caregivers to make informed decisions about their care and support options.
• Build and maintain relationships with healthcare providers, community organizations, and other stakeholders to facilitate integrated care.
• Lead and collaborate with interdisciplinary care team (ICT) to discuss individual cases, coordinate care strategies, and create holistic care plans that address medical and non-medical needs.
• Provide education and resources to members and their families/caregivers about available services, benefits, and community resources.
• Offer guidance on navigating the healthcare system and accessing necessary supports.
• Maintain accurate and up-to-date records of member interactions, care/service plans, and progress notes.
• Assist in preparation of reports and documentation required for compliance with state and federal regulatory requirements.
• Respond to crises or emergencies involving members receiving waiver services, coordinating immediate interventions and support as needed.
• Evaluate member satisfaction through open communication and monitoring of concerns or issues.
• Regular travel to conduct member, provider and community-based visits as needed and per the regulatory requirements of the program.
• Report abuse, neglect, or exploitation of older adults as a mandated reporter as required by State law.
• Regularly verify and collaborate with Job and Family Service to establish and/or maintain Medicaid eligibility.
• On-call responsibilities as assigned.
• Perform any other job related duties as requested.

Community Based Waiver Service Coordinator

Network Operations

• The Director, Health Partner Engagement directs, oversees, and manages strong relationships with key Health Partners throughout the state
• Identifies and fosters communications with Health Partners to reduce high cost utilization trends
• Works with Health Partner stakeholders to evaluate policy and process changes for potential impacts
• Manages Health Partner Relations team that conducts research into Health Partner issues and drives them to completion for the Health Partner network
• Consults with Health Partner Contracting leadership to assist in the development and execution of negotiation plans
• Directs Health Partner Relations staff to assure day-to-day activities are performed effectively and support the market’s network strategy