CareSource

Actuary

• Provides timely, accurate, and actionable data and analysis supporting the department, area, and corporate key initiatives
• Develops actionable recommendations to management relative to all analysis
• Calculates profitability reports on appropriate business segments
• Performs regular and ad-hoc analysis to identify opportunities to improve efficiency and affordability
• Participates in cross functional teams to address key issues facing the organization
• Prepares monthly calculation of the company's IBNR reserves
• Evaluates government reimbursement process to determine areas of risk and opportunity
• Participates in initiatives to improve operating results
• Initiates key analysis to improve overall MLR results
• Performs other duties as assigned

Actuarial Analyst I

Content Marketing Manager

• Create and manage core CareSource messaging, narratives and content that complies with company policies, brand standards, and applicable regulatory requirements
• Develop and maintain a wide variety of communications content, including key messaging documents, thought leadership, health communications, FAQs, video and multimedia content, high-impact external communication materials, and internal resources such as leadership briefings and campaign reports
• Coordinate, monitor and track external speaking opportunities and thought leadership commitments, materials and briefings across the organization
• Assist in the creation and maintenance of a suite of corporate materials, including core slides, fact sheets, and other communications assets
• Partner with business and marketing teams, as well as outside agencies, to support marketing and/or communications campaigns
• Coordinate with internal teams to leverage content and campaigns across internal platforms, including the company intranet, employee newsletters, and other relevant channels
• Collaborate cross-functionally to manage programs, evaluate effectiveness, and communicate campaign results
• Identify opportunities for process improvements and assist with special projects as assigned
• Perform any other job related duties as requested

Communications & Content Governance Specialist III

Medical Director

• Development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives
• Development of policies and procedures
• Medical Director Operational leadership, Medical Economics Analytics
• Identify utilization management trends and take appropriate action
• Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
• Support staff by providing training, clinical consultation, and clinical case review for members
• Participate in peer-to-peer discussions
• Provide provider education, training, data sharing, performance evaluations and orientation to the plan
• 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
• Provide prior authorization medical reviews, consultation and clinical review services
• Conduct clinical reviews for designated CareSource members
• Collaborate with market/product leaders to help define market strategy
• Provides oversight and direction of assigned managers and associates
• Perform any other job duties as requested

Enterprise Medical Director

Analyst

• Analyze and interpret complex healthcare data
• Collaborate with cross-functional teams, providing analytical insight to inform strategy and interventions
• Generate comprehensive reports, graphics, and dashboards that effectively summarize and display data for key stakeholders
• Review reports and data for pattern identification and trend analysis, providing management level summaries
• Provide technical expertise and guidance to team members on SQL, SAS, and DAX coding best practices
• Interpret and maintain understanding of technical specifications and quality reporting requirements
• Interact and work collaboratively with business partners on analytics requests and identifying trends
• Collaborate with IT teams to enhance data collection and reporting systems
• Perform any other job duties as assigned

HEDIS Quality Analyst III

Manager

• Leads DSNP bid development strategy, execution, and submission activities across all applicable states and plan years.
• Interprets CMS guidance, Final Rules, and HPMS memos to inform DSNP bid design and compliance requirements.
• Partners with Actuarial, Finance, Compliance, Product, and Operations to ensure bid accuracy, alignment, and feasibility.
• Oversees benefit design decisions, supplemental benefit strategy, and competitive positioning for DSNP products.
• Manages CMS Model Materials Timeline.
• Provides leadership on mid-year benefit changes, plan corrections, and CMS resubmissions as needed.
• Conducts bid reviews and risk assessments to identify financial, operational, and regulatory exposure.
• Maintains bid documentation, assumptions, and audit-ready artifacts for internal and external review.

Senior Manager, DSNP Bid Strategy – Development

Human Resources

• Serve as a strategic advisor on employee relations
• Create and implement positive employee relations strategies and practices
• Partner with HRBP team and CoE’s to drive proactive change management
• Conduct thorough, timely, and well-documented investigations
• Analyze employee engagement metrics and case trends

Employee Relations Partner – III

Director

• Drive member retention performance
• Define and implement a coordinated, cross-functional plan throughout the organization
• Develop and oversee member retention strategies and related work plans
• Monitor retention metrics and analyze trends
• Represent the work and outcomes to leadership and external stakeholders

Senior Director, Member Retention – Managed Care, Operational Experience Preferred

• Managing day-to-day activities of care coordination
• Ensuring delivery of quality service and performance of the staff and team
• Providing support to the team for care management issues, problem resolution, complaint resolution and other member services related issues
• Managing and coordinating the activities of RSH MLTC care coordination team
• Performing all duties inherent in the managerial role
• Ensuring staff training and evaluating staff performance
• Participating in hiring, retention, evaluation, disciplining and termination of staff
• Ensuring compliance with NY State Department of Health regulations
• Conducting yearly evaluations of employees’ performance
• Developing job descriptions for personnel
• Assuring adherence to good personnel practices
• Overseeing the clinical supervision of staff
• Representing Program to the community
• Performing outreach, marketing and liaison responsibilities

Assistant Clinical Director – Hybrid

Operations

• Serve as the primary operational lead for LTSS service determinations within an assigned market(s), ensuring alignment with state‑specific program rules, waiver requirements, contractual obligations, and workflow nuances.
• Act as the key market‑level liaison for LTSS service determinations, partnering with local Care Management, Clinical, Product, and Compliance stakeholders to ensure operational readiness and issue resolution.
• Ensure timely and accurate determinations in alignment with medical necessity guidelines, benefit rules, and regulatory requirements.
• Drive consistency in service determinations across PCA, GAFC/AFC, Home Health, and Flexible Benefits.
• Serve as the primary operational owner of the service determination workflow (interim and future-state).
• Provide input into process design, rollout strategy, and system enhancements, ensuring operational feasibility and scalability.
• Identify gaps, inefficiencies, and variation in decision-making and implement standardized solutions.
• Lead continuous improvement initiatives focused on quality, turnaround time, and member experience.
• Develop and execute training and onboarding programs for new and existing staff.
• Ensure team readiness for new workflows, regulatory updates, and system changes.
• Partner with CM, Clinical and Compliance teams to ensure staff are trained on medical necessity guidelines and LTSS program distinctions.
• Directly manage and develop a team of service determination professionals.
• Provide coaching, mentorship, and performance management to drive high-quality outcomes.
• Monitor key performance indicators.
• Identify and mitigate risks related to service misalignment, duplication of services, and documentation gaps.
• Perform any other job related duties as requested.

Manager, LTSS Service Determination Operations

• Provide leadership and direction to Rapid Response Team and Incident Management Team
• Oversee centralized escalation and incident management processes
• Ensure timely, compliant, and high-quality resolution of issues
• Manage staff to ensure accurate and high-quality completion of escalations
• Oversee intake, triage, and resolution of escalations
• Ensure tracking and monitoring of critical incidents
• Comply with all regulatory requirements
• Manage escalation and incident management systems

Manager, Rapid Response – Incident Management Operations

Product Operations

• Provides end-to-end operational leadership for DSNP products
• Ensures regulatory compliance, scalability, and readiness across markets
• Owns operational execution for DSNP benefit configuration, eligibility, enrollment
• Partners closely with Product, IT, Compliance, Clinical teams to translate DSNP strategy
• Oversees operational impacts of CMS guidance, state requirements, and dual integration models
• Drives continuous improvement initiatives to enhance operational efficiency
• Establishes and monitors KPIs, SLAs, and operational risk indicators related to DSNP performance
• Manages team supporting operational oversight of vendor delegated for supplemental Food/OTC/Flex cards

Senior Manager, DSNP Product 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.

Registered Nurse (RN), Clinical Care Manager

Events

• Ensure that members eligible for Medicaid benefits receive outreach for informing, screening, tracking, diagnostic and treatment services available under the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit
• Responsible for execution, monitoring and reporting of Quality or Preventive Health Programs and strategies (i.e., School Based Health Centers, Telehealth), including supporting members with educational materials according to clinical best practice guidance
• Participate in quarterly market Quality Improvement and population health management workgroups
• Facilitate completion of the annual evaluation report for assigned market/product
• Attend telephonic Health Partner meetings with top providers; engage in population and rural provider strategy
• Telephonically contact eligible members and providers to discuss all preventive care needs, benefits and their current gaps in care
• Ensure that contractual/regulatory requirements for prevention services are met
• Collaborate with enterprise quality for all prevention services, analysis of data and reporting
• Be fully versed in individual state clinical/programmatic contract management requirements
• Collaborate closely with members’ assigned case managers to coordinate care and programs
• Prepare weekly, monthly, quarterly and annual reports of outreach activities
• Perform any other job duties as assigned

Prevention Health Specialist

Data Analyst

• Responsible for extracting, analyzing, reporting, tracking and monitoring provider data across business functions, systems and interfaces
• Manage new HPLC initiatives from concept to implementation and provide statistics measuring progress
• Participate as a member of Health Partner Lifecycle (HPLC) team to support existing provider data operations and new market implementations
• Perform cost-benefit and return on investment analyses for proposed initiatives to aid in the decision-making process
• Ensure operational effectiveness by assisting in the development of strategic plans for HPLC
• Assume a leading role in the operational readiness process
• Prepare and deliver summaries, recommendations, or alternatives of the analyzed information
• Mentor peers to achieve cross-functional capability with project execution and subject matter expertise
• Perform any other job related duties, as requested

Health Plan Data Analyst III, Health Plan & Provider Experience

Account Manager

• Serves as the primary field-based liaison between the organization and DSNP-participating providers, nursing facilities, and long-term care partners.
• Builds and maintains strong, trusted relationships with facility leadership, administrators, and clinical staff to support DSNP program success.
• Conducts regular on-site visits to nursing facilities and provider offices to support education, issue resolution, and operational alignment.
• Acts as the local DSNP subject matter expert for providers, addressing questions related to benefits, eligibility, enrollment, and care coordination.
• Identifies operational, clinical, or administrative barriers impacting DSNP members and works cross-functionally to drive timely resolution.
• Supports onboarding and ongoing engagement of DSNP-participating facilities, ensuring understanding of program requirements and workflows.
• Collaborates with internal Clinical, LTSS, Operations, and Network teams to improve member outcomes and provider experience.
• Monitors provider performance indicators and escalates risks or trends that may impact quality, access, or compliance.
• Provides feedback from the field to inform DSNP product design, operational improvements, and network strategy.