CareSource

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.
• Keeps management informed by documenting detailed activity and records of all agency/organization contacts in the Customer Relationship Management tool (“CRM”) and weekly reports.
• 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.
• Documents provider interactions, issues, and follow-ups to ensure visibility, accountability, and continuity across teams.

Data Engineer

• Key contributor for data stewardship workgroups and teams in data management and governance activities
• Champion of metadata and data quality practices across the organization
• Accountable and responsible for the engineering success of specific data governance engineering programs
• 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
• Collaborate with SMEs to develop business rules that measure and assure data quality
• Lead efforts to quantify and qualify reported data quality issues

Data Engineer II

Medical Director

• responsible for managing the day-to-day activities of care coordination
• ensures delivery of quality service and performance of the staff and team
• provides support to the team for care management issues, problem resolution, complaint resolution and other member services related issues
• manages and coordinates the activities of RSH MLTC care coordination team
• performs all duties inherent in the managerial role
• ensures compliance, consistent with health rules of the New York State Department of Health
• develops policies and procedures governing client care
• recruits and provides sufficient staff required to meet the Program’s responsibilities
• oversees the clinical supervision of staff to assure standards of care are met
• represents Program to community
• performs outreach, marketing and liaison responsibilities

Assistant Clinical Director – Queens Office

Manager

• Collaborate with members of an inter-disciplinary care team (ICT) to meet the needs of members admitted to behavioral health facilities or receiving behavioral health services
• Engage the member and complete a health and psychosocial survey
• Participate in development of an individualized care plan (ICP)
• Identify and manage barriers to achievement of care plan goals
• Coordinate, communicate and collaborate with the member and the ICT in order to achieve goals and maximize positive member outcomes
• Educate the member/caregivers about risk conditions, community resources, insurance benefits, etc.
• Document care coordination activities and member response in a timely manner

Behavioral Health Case Manager

Data Scientist

• Provide leadership for a multidisciplinary data science team using AI and ML technologies
• Develop predictive models, ML algorithms, and statistical techniques to enhance healthcare operations
• Collaborate with architecture and data solutions teams to move solutions from prototype to production
• Ensure compliance with HIPAA/PHI handling and internal governance standards

Senior Manager, AI and Data Science

Product Manager

• Ensure compliance with interoperability mandates and legal requirements
• Collaborate with internal teams to establish data sharing agreements
• Drive alignment across business and IT teams on FHIR endpoints

Interoperability Product Owner

Operations

• The Manager, Utilization Management (UM) Strategy & Implementation leads a dedicated team that supports the UM program through multiple functions with a focus on all regulatory and compliance functions.
• Oversee and manage UM Operations oversight functions such as Corrective Action Plan (CAP) management, ongoing monitoring, and multiple audit activities.
• Build and leverage effective cross-functional business relationships and influence action across multiple internal and external partners to support a culture of compliance.
• Responsible for development and maintenance of documentation related to policy, workflow and process when applicable.
• Identify process gaps and drive improvements towards UM compliance in all areas.

Manager, UM Operations Strategy – Implementation

• Manage a team of Information Technology professionals
• Provide leadership, vision, management goals, priorities, metrics, measures, recognition and discipline
• Responsible for the relationship between key business stakeholders and IT and accountable for the team’s delivery of the associated business services
• Set vision and direction of department
• Responsible for the team’s execution of assigned work
• Develop strategy and high-level implementation plans for the delivery of new technology
• Evaluate, validate, and communicate the business proposition associated with new technology initiatives
• Improve solution functionality and efficiency with added business value as the goal
• Liaise closely with other business areas to optimize the use of systems and applications
• Systematically evaluate currently deployed services; develop and manage plans to optimize delivery and support mechanisms
• Regularly assess the associated technology platforms

Manager, Information Technology

Data Analyst

• Extracting, analyzing, reporting, tracking and monitoring provider data across business functions, systems and interfaces
• Support existing provider data operations and new market implementations
• Perform disruption analysis activities for assigned markets
• Serve as Project Manager for select HPLC initiatives
• Develop Performance Improvement initiatives and corrective action plans to improve quality of provider data
• Coordinate activities with regard to provider network data management and reporting
• Develop database structures and reports as needed
• Review provider organizations and systems for analyses that support contract negotiation and provider recruitment processes

Health Plan Data Analyst II, SQL required

Financial Planning and Analysis

• Provides financial oversight, leadership, and support to the market/corporate
• Manages the execution of the annual budget/quarterly forecast
• Works with senior management and team to implement new business activities and process improvements
• Develops strategy supporting the FP&A function
• Responsible for budget to actual analysis monthly
• Provides support for proforma work related to RFPs, mergers, and acquisitions for new business activities
• Responsible for end-to-end planning process including project management oversight
• Responsible for contract reviews for administrative costs
• Guides and oversees the process for compilation of data and reporting
• Provides insight into the risk sensitivity associated with current and future business drivers
• Responsible for ensuring budget policy and procedures are in compliance with Model Audit Rule requirements
• Participates in various meetings with leadership including strategic planning
• Performs ad hoc and trending analysis
• Responsible for staffing decisions, management of departmental staff and expense budget

AVP, Finance

• Responsible for oversight of all Clinical Pharmacy activities ensuring consistency in delivery of services and achievement of utilization targets
• Assist in coordination and management of the pre-determination process for specialty pharmacy
• Assist in the development of integrated service delivery to members and oversee data and processes to maintain industry standards and practices
• Assist the Director in developing processes to manage appropriate utilization and assure appropriate payment for services
• Interact with providers and staff to manage benefits aligned with regulations, URAC and NCQA regulations and CareSource policies and vision
• 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 specialty pharmacy data
• Ensure compliance with and reporting of all regulatory requirements
• Analyze and formulate recommendations based on data
• Maintain and update all departmental policies and procedures
• Act as liaison with other departments to assist with research and intervention
• Empower staff to achieve goals
• Coach, develop, and motivate team
• Foster positive working relationships with internal departments and external providers
• Perform any other job related instructions as requested

Manager, Clinical Pharmacy Operations

Director

• Responsible for hospital, provider and ancillary provider contracting
• Facilitate optimal member access and successful business growth initiatives
• Develop a Contracting Strategy for various targeted markets
• Responsible for robust competitor and provider analysis
• Ensure provider network is adequate and meets requirements
• Interact with Finance Department on pricing for provider contracts
• Implement performance improvement initiatives for Provider Satisfaction Scores

Director, Network Development

• The Nurse Care Manager is 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
• Performs home visits as required to assess members’ living situation
• Collaborates with the primary care physician and Inter-Disciplinary Team to develop the Patient Centered Service Plan for the member
• Identifies same day grievances, investigates and documents accordingly

Registered Nurse (RN) Care Manager – MLTC

• Engage with the enrollee in their homes and community settings to establish a complex care management relationship.
• Function as a liaison between healthcare providers, community resources, and enrollees.
• Perform required assessments in a timely basis, including Comprehensive Assessment and Crisis and Risk Assessments.
• Develop and implement care plans while providing updates as enrollees’ status changes.
• Lead the interdisciplinary care team (ICT) and collaborate to create holistic care plans.
• Oversee enrollee utilization of long-term services and supports.
• Assist members in accessing community resources, including housing and social services.
• Educate members about managing chronic conditions and preventive care.
• Follow up with members after significant health events to ensure continuity of care.
• Advocate for enrollees' needs within the healthcare system.

Clinical Care Manager, RN, LICSW, LMHC

Vice President

• Lead Ohio Department of Medicaid (ODM) contractual requirements, such Network Development Management Plan (NDMP), Network adequacy, Provider Engagement and Education
• Oversee Provider’s operational strategy for Ohio
• Ensure evaluation and outcomes and alignment across senior leaders to ensure Provider contracting, network and relations are measurable
• Oversee collaboration with market and enterprise workgroups to ensure alignment and overall implementation of Ohio strategy
• Represent Ohio Market Leadership as panelist and subject matter expert
• Collaborate with the Ohio Executive team to ensure provider contracting and engagement performance
• Build, maintain and improve all structure and processes necessary to assure impeccable regulatory record
• Collaborate, innovate and support provider approaches to address contract compliance
• Coordinate and collaborate with providers, local and state government, community-based organizations, ODM, and other ODM-contracted managed care entities
• Develop health plan Network policies, procedures and goals as needed
• Monitor health plan Network budgets; describe variance detail monthly with effective action plans
• Produce team results that demonstrate engagement rates, low Grievances & Appeals, Continuous Improvement, Human Capital metrics