CareSource

Software Engineer

• Generate complex reports and dashboards to track KPIs and metrics related to LTSS & Dual Program reporting impacting patient care, operational efficiency, and financial performance; utilizing statistical methods and machine learning techniques to identify trends, forecast future outcomes, and drive actionable insights
• Design and develop dynamic, user-friendly dashboards using business intelligence tools (e.g., Tableau, Power BI) for stakeholders at various levels of the organization.
• Continuously enhance and update dashboards to ensure data relevance, accuracy, and timeliness
• Analyze and evaluate current operations processes to identify opportunities for optimization, cost reduction, Case manager effectiveness and improved patient experience
• Recommend strategies for improving operational efficiency and implementing changes to workflows in alignment with business objectives
• Ensure high levels of data accuracy, integrity, consistency, and completeness through effective data governance practices
• Work closely with data engineering teams to ensure data is sourced and integrated from multiple systems with high reliability
• Develop LTSS & Dual Program reporting solutions that are scalable and include efficient database solutions for supporting reporting functionality
• Work in close collaboration with cross-functional teams to better understand data needs
• Create ETL solutions for automated, scheduled data refreshes and regular report delivery
• Develop and deploy Power BI dashboards which provide leadership with actionable insights that drive critical business decisions
• Transform data sets and quantitative and qualitative analysis into usable and effective data for department leaders to make informed business decisions
• Build complex analytic tools that utilize the data pipeline to provide actionable insights and other key business performance metrics, historical trends or benchmarks
• Identify, design, and implement internal process improvements, automating manual processes, optimizing data delivery
• Perform complex analysis on data to provide insight and address critical business questions
• Transform data analysis and present findings in a consumable, appealing, and impactful executive level format
• Create cohesive, cross-functional strategic plans for developing complex data solutions
• Gather and analyze data, define and document business requirements, recommend technology requirements, review functional specs, and test relevant systems
• Develop, document and perform testing and validation as needed
• Conduct examination, testing activities, and explanation of complex data relationships to answer questions identified by the business/department
• Create, implement and enforce coding standards for the team
• Lead and participate in complex, large-effort data transformation and visualization projects which require cross functional coordination and collaboration across teams
• Performs any other job related duties as requested.

LTSS & Dual Eligible Program Report Developer IV

Manager

• Responsible for providing care coordination including in-home assessment, planning, facilitation, advocacy and authorization of covered plan services
• 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
• 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
• 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

Registered Nurse Care Manager

Analyst

• Prepare and review integrated reporting on health partner incentive programs for management on a timely and accurate basis
• Identify trends, develop competitive analysis, and present findings to senior management
• Evaluate and make appropriate improvements to internal analysis processes ensuring practices are in line with overall goals
• Ensure contract implementation and maintenance reflect corporate Value Based Reimbursement (VBR) program definitions
• Monitor and track implementation of new health partner payment/incentive programs
• Provide recommendations on program enhancements supported by research and analysis
• Conduct/review complex user acceptance testing for incentive application development
• Develop SOPs related to health partner payment/incentive configuration and maintenance across multiple functional areas

Health Partner Incentive Analyst III

Medical Billing and Coding

• Generate comprehensive and concise in-depth reporting and analysis for Pre-Pay and Post-Paid Processes
• Provide Provider Pre Pay production and progress reports and coordinate with management and team
• Recommend process or procedure changes and build strong relationships with cross departmental teams
• Demonstrate leadership ability, including mentoring Program Integrity Claims Analysts
• Identify knowledge gaps and provide training opportunities
• Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws
• Responsible for making claim payments decisions on a variety of claims
• Respond to claim questions and concerns and prepare claims for Medical Director review

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

• Drive day to day progress across the portfolio of strategic growth efforts
• Build reporting and governance structures for initial oversight
• Identify, escalate and address immediate priorities
• Partner with Sales/Business Development, Operations, Clinical, Technology, Account Management and Marketing teams
• Drive prioritization of instED efforts in support of implementing strategic growth initiatives
• Develop budgets, identify resource needs, and develop and maintain financial models

Senior Implementation Manager

Community Manager

• The Community Based Care Coordinator I is the member concierge and the single point of contact for assessment, person-centered planning, service coordination, disease management and transitions between all levels of care.
• Understand and implement person-Centered thinking
• Facilitate the person-Centered planning process
• Assist with in person-centered care training to maximize the development of the Person-Centered Service Plan.
• Coordinate services and health benefits for members who meet criteria
• Consult with members, families and legally responsible people to discuss behavioral and physical health care needs
• Consult and collaborate with other professionals and community members to coordinate care and develop Person-Centered Service Plans
• Assist with ongoing communication with the internal complex clinical team.
• Assist with educating members about their condition, medication and assist with any necessary instruction.

Community Based Care Coordinator I

Systems Engineer

• Collaborate with internal and external stakeholders to elicit business concerns and define system requirements
• Examine existing IT systems, translating requirements into actionable user stories
• Ensure that documentation is maintained throughout the development lifecycle
• Serve as a Subject Matter Expert (SME) for assigned applications
• Perform root cause analysis and triage defects and incidents

Systems Analyst II

Learning and Development

• Partner with HR Business Partners, business leaders and stakeholders to assess learning needs
• Conduct comprehensive needs assessments to create and implement customized learning and development plans
• Translate business objectives into learning strategies, curricula and roadmaps
• Design and deliver high-impact, learner-centered development experiences including virtual instructor-led training
• Create clear instructional materials that adhere to brand and learning objectives
• Apply various facilitation methods to deepen understanding and behavior change
• Manage project details and use data to refine learning outcomes
• Define and track key metrics and effectiveness measures for all learning initiatives
• Perform any other job related duties as requested

Talent Development Partner III

• Implement optimization opportunities for prepay and post pay medical record auditing procedures and processes improvement auditing timeliness and quality outcomes
• Oversee and ensure that supporting business and regulatory processes and documentation exists and kept current
• Track and communicate production issues and escalations to ensure proper follow-up and coordination
• Maintain project plans for all projects in which configuration is involved and ensure proper completion of those plans and escalation where timeframes will be changed
• Lead new product and new vendor implementations to ensure timeliness and quality of new implementations
• Develop and implement ticket controls and ensure that proper communication and approvals are in place prior to system implementation
• Oversight and management of team of medical record coding auditors
• Analyze and make a determination of appropriate reimbursements and/or modifications of Coding review guidelines in partnership with medical directors and clinical staff.

Senior Manager, Program Integrity – CPC, RHIT, RHIA required

Business Analyst

• Establish and maintain strong relationships with senior stakeholders to understand business goals and drive alignment on strategic initiatives
• Review project artifacts such as business cases, contracts and architectural diagrams to ensure alignment with business objectives and requirements
• Identify, sequence, create, and maintain Epics throughout their lifecycle
• Lead teams in complex requirements elicitation efforts using advanced facilitation and modeling techniques
• Ensure comprehensive requirements documentation and traceability that aligns with strategic objectives
• Collaborate with executive leadership, IT, product management, and other departments to ensure cohesive strategy execution and successful implementation of requirements

Business Analyst IV

Vice President

• Collaborates closely with both Market and Corporate Leadership to ensure the effective delivery of care for multiple markets
• Accountable for collaborating with Market and Corporate Leadership to support the strategy and operations of dual product care management
• Responsible for providing direction and oversight of dual product care management activities across the continuum and coordination of care
• Ensure programs and operational processes within regional markets are properly developed and aligned with the corporate Care Management model
• Assign appropriate priorities according to the overall business plan
• Lead, implement, develop, and support programs, systems, and processes to ensure consistent, effective, and efficient delivery of care to CareSource complex and dual product members while meeting state regulations and market financial objectives
• Cultivate and promote the CareSource culture to improve the health outcomes of our members
• Develop, implement, and monitor an accountability system and succession planning strategies
• Monitor CQI activities and process improvement in accordance with regulatory requirements, URAC, HEDIS, NCQA, and future business needs related standards
• Foster external and internal relationships with hospitals, physicians, community agencies, and key vendors
• Budget responsibility related to clinical care, direct actions to control targeted costs for inpatient and outpatient services in conjunction with market Medical Directors and corporate clinical and analytics leadership
• Review periodic reports (financial/utilization/services) to analyze trends, implement timely corrective action plans, and ensure consistent, accurate data according to established policies and procedures

AVP, Dual Products

• Responsible for oversight of development, execution and implementation of the LTSS model
• Direct, execute and manage strong relationships with key partners throughout the enterprise
• Develops, performs, and promotes interdepartmental integration and collaboration
• Establish strong operational metrics and auditing to ensure quality and compliance
• Collaborate with market and executive leadership to formulate and implement business strategies
• Establish post-implementation strategy and goals to mitigate program risks
• Evaluates operational process effectiveness and manages operation process improvement activities
• Provide leadership and support for product expansion
• Recognizes and proactively manages operational dependencies and risks across market operations initiatives
• Build strong working relationships with all markets and ensure alignment
• Lead activities ensuring high-quality initiatives that result in optimum outcomes for members, providers, and program goals
• Recruit, develop, and lead key staff

AVP, LTSS

Operations

• Lead the development of the overall Marketplace Program Strategy
• Establish and strengthen trusted advisor relationships with Enterprise functional business leaders
• Achieve a strong understanding of the Marketplace program elements that drive performance
• Partner with stakeholders to develop Marketplace program KPIs and metrics
• Evaluate administrative spend for the Marketplace program
• Execute Enterprise strategic initiatives as it relates to performance / process improvements
• Partner with the Consumer Experience team to identify and execute enterprise / market-level consumer improvement initiatives
• Accountable for hiring, training, coaching, performance appraisals and motivating collaboration
• Develop budget for area of responsibility

Senior Director, Product Performance & Operations

Financial Planning and Analysis

• Prepare analysis for utilization and financial trends, costs, revenues, financial commitments and obligations incurred to predict future revenues and expenses; understand financial impacts of decisions and communicate those to management
• Highly involved in the development, production, and validation of reports from detailed claims, eligibility, pharmacy and clinical data
• Compile and analyze financial and clinical information, including but not limited to preparing the evaluation of medical contracts, product lines, generating and managing medical and administrative cost saving initiatives, etc.
• Ensure integrity of information obtained for analysis; keep an up-to-date knowledge of the computer information system
• Develop competitive analysis and present findings to senior management
• Prepare revenue and medical expense forecast and budget and monitor monthly variances to identify trends
• Identify and research trends and patterns using standard departmental reports and databases, as well as leveraging other processes and data sources for data mining
• Make appropriate improvements to internal analysis processes ensuring that practices are in line with the overall goals of the organization
• Support the financial control environment by reconciling internal data sets vs information provided by the State (such as, reconcile enrollment files to reimbursement records, etc.)

Financial Analyst II

Sales

• Identify and educate consumers about the CareSource exchange product lines
• Generate enrollment leads and referrals
• Support enrollment of eligible consumers in the CareSource plan
• Facilitate enrollment growth in the product
• Assist prospective members with selecting and enrolling in the CareSource exchange health plan
• Educate members on benefits and services, plan premiums, co-pays and coinsurance
• Answer all Healthcare Exchange inquiries
• Assist with application process for enrollment
• Serve as a subject matter expert on CareSource exchange healthcare plans and product lines
• Assist members with navigating the healthcare system
• Order member ID cards
• Resolve pharmacy inquiries
• Resolve escalated member complaints
• Consult with support departments for expedited resolution
• Inform members of premium payment options
• Make proactive outbound sales calls based on identified leads or campaigns
• Ensure compliance with HIPAA and State/CMS requirements and regulations
• Maintain documentation of all communications with members and prospective members
• Build and strengthen member relationships by providing world class customer service
• Research, follow up, and resolve all open/pended issues in a timely manner
• Make contact with potential members and successfully quote their insurance premiums
• Service and provide information regarding applicable changes to their policy
• Adhere to all departmental and company policies and procedures