CareSource

Manager

• The Clinical Care Manager is responsible for providing 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 a complex care management relationship.
• Function as a liaison between healthcare providers, community resources, and enrollees.
• Perform required assessments on a timely basis, including Comprehensive Assessment, MDS-HC (or successor) Functional Assessments, and Crisis and Risk Assessments.
• Lead the interdisciplinary care team (ICT) to create holistic care plans.
• Oversee enrollee utilization of long-term services and supports.
• Assist members in accessing community resources like housing, food assistance, etc.
• Provide education to members and families about managing chronic conditions and preventive care.
• Follow up with members after hospitalizations to ensure continuity of care.
• Advocate for the needs and preferences of enrollees within the healthcare system.

Registered Nurse, Clinical Care Manager

• Oversees small- to large-scale programs supporting strategic network objectives
• Lead delivery of HCBS and LTSS network program initiatives in alignment with market and enterprise strategies
• Interpret business and regulatory requirements to enable effective cross-functional coordination
• Ensure timely completion of program deliverables in compliance with regulatory and leadership approvals
• Drive continuous improvement through adoption of best practices, processes, and tools
• Partner with functional leaders to define, assign, and track work supporting approved network strategies
• Collaborate with market network leadership to ensure programs are appropriately resourced and managed
• Maintain stakeholder engagement and communication, including issue escalation and resolution
• Serve as subject matter expert and liaison for HCBS and LTSS strategic and operational partnerships
• Support operational readiness for RFPs, implementations, onsite readiness, and program transitions
• Develop market-specific HCBS/LTSS analyses for RFPs, including network landscape, competitiveness, and state requirements
• Support contracting discussions for multi-market HCBS/LTSS network partnerships
• Coordinate development of HCBS/LTSS provider-facing materials, contracting documents, compensation models, and training resources.
• Perform any other job related duties as requested.

LTSS and HCBS Provider Network Manager

Financial Planning and Analysis

• The Financial Analyst I assists in the analysis for utilization and financial trends, costs, revenues, financial commitments and obligations incurred to predict future revenues and expenses.
• 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
• Assist in the development of revenue & 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
• Suggest 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.)
• Utilize key analysis experience and knowledge to analyze and report medical, contract and administrative activity
• Make appropriate changes to ensure compliance with MAR, regulatory and other organization requirements
• Perform any other job related instructions as requested

Financial Analyst I

Medical Director

• Provide prior authorization medical reviews, consultation and clinical review services
• Participate in peer-to-peer discussions
• Provide provider education, training, data sharing, performance evaluations and orientation to the plan
• Conduct clinical reviews for designated CareSource members as requested
• Provide physician review for clinical appeals cases
• Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
• Participate in development of policies and procedures
• Participates in quality improvement initiatives, case management activities and member safety activities
• Provide cross-coverage for other Medical Directors and/or markets, as needed
• Oversight and quality improvement activities associated with case management activities
• Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate
• 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
• Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs

Medical Director, Massachusetts

Analyst

• Responsible for the mergers & acquisition workstream, business planning, and work product development for the Business Development team.
• Coordinate the execution of diligence planning items and activities among various teams
• Manage the due diligence workstream
• Support internal transaction review and analysis
• Coordinate meeting facilitation among the deal, functional, legal, outside advisory teams, and internal senior leadership
• Document and communicate the status, risks, issues, and interdependencies and among various teams
• Develop meeting, presentation, and executive reporting materials
• Collaborate with other functional areas and subject matter experts

Business Insights & Planning Analyst III

• Responsible for analyzing utilization and financial trends, costs, revenues, financial commitments and obligations incurred to predict future revenues and expenses
• Manage 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
• 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
• Responsible for the development of membership projections, medical expense forecast and budget and monitor monthly variances to identify trends
• Proactively identify trends and patterns using standard departmental reports and databases as well as leveraging other processes and data sources for data mining
• Evaluate and 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
• Utilize key analysis experience and knowledge to analyze and report medical, contract and administrative activity
• Make appropriate changes to ensure compliance with MAR, regulatory and other organization requirements

Financial Analyst III – Cost Reporting

• Provides care coordination including in-home assessment, planning, facilitation, advocacy and authorization of covered plan services
• Ensures consistent care along the entire health care continuum
• Collaborates and communicates with member/family/caregivers and interdisciplinary team
• Conducts home visits to assess members’ living situation
• Develops efficient plans of care authorizing needed services

Registered Nurse (RN) Care Manager – MLTC

Program Manager

• Own and manage the enterprise vendor financial governance program, including standards, controls, workflows, documentation, and performance monitoring.
• Establish and maintain governance frameworks to ensure vendor financial terms are implemented and maintained in alignment with contractual, regulatory, and operational requirements.
• Serve as a primary point of accountability for vendor financial governance issues, risks, and escalations.
• Act as a strategic liaison across Finance, Operations, Compliance, and Markets to ensure vendor payments are accurate, timely, and aligned with contract terms, performance standards, and business expectations.
• Influence and coordinate stakeholders to drive alignment, resolve issues, and ensure consistent execution of vendor governance practices across the enterprise.
• Represent Finance Vendor Governance in enterprise-wide workgroups and initiatives, advancing standardization and program maturity.
• Serve as a subject matter expert for vendor and provider contracts by interpreting financial, business, and regulatory terms and translating them into operational requirements and controls.
• Provide guidance to internal stakeholders on contract interpretation, financial implications, and governance requirements.
• Oversee vendor performance monitoring, including SLAs, deliverables, turnaround times, and reporting requirements.
• Develop, track, and manage performance improvement plans, including financial penalties, credits, and utilization metrics to ensure adherence to contractual obligations.
• Identify and address performance, compliance, and financial risks through data driven analysis and corrective action planning.
• Lead preparation for and support internal and external audits, regulatory reviews, and risk decision memorandums (RDMs) related to vendor sourcing, oversight, and financial controls.
• Ensure documentation, controls, and processes support audit readiness and regulatory compliance.
• Drive continuous improvement initiatives related to vendor onboarding, implementation, payment processes, and compliance readiness.
• Analyze data and reporting to identify gaps, risks, and opportunities to improve vendor performance, payment accuracy, and operational efficiency.
• Develop and maintain program documentation, including contracts, templates, playbooks, and standard operating procedures, ensuring consistency and scalability.
• Prepare and deliver market level and enterprise reporting on vendor performance, financial compliance, risks, and program outcomes.
• Serve as a liaison between market stakeholders and corporate teams to ensure transparency, alignment, and issue resolution.

Finance Vendor Governance Program Manager

Scrum Master

• Organize and lead initiatives to further incorporate and standardize Agile principles within the organization
• Lead or participate in cross team initiatives to propagate Agile maturity across IT, business, and PMOs
• 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 multiple teams and organization
• Coach the teams 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, with an emphasis of healing and problem solving
• 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
• Coach, support, and educate the Product Owner, especially with respect to refining and managing the product backlog
• Establish and foster effective product owner universe in complex stakeholder environments to further the team’s productivity and quality

Scrum Master III

• Collaborates with members of an inter-disciplinary care team (ICT), providers, community and faith-based organizations to improve quality and meet the needs of the individual
• Engages with the member and their natural support system through strength-based assessments and trauma-informed care
• Develops and regularly updates a person-centered individualized care plan (ICP) in collaboration with the ICT
• Identifies and manages barriers to achievement of care plan goals
• Facilitates coordination and communication with the member and ICT to achieve goals and maximize positive member outcomes
• Educates the member/natural supports about treatment options, community resources, insurance benefits, etc.
• Documents care coordination activities and member response in a timely manner according to standards of practice

Mom and Baby Care Manager – RN

Operations

• Support standardization, management of data, and workflow optimization for the Medical Affairs team
• Oversee long term tracking and trending of high priority items
• Manage and report on productivity and performance metrics
• Develop consistent and standardized reporting across all teams
• Investigate and analyze issues identified by leaders through data
• Support Key Performance Indicators (KPI) review for potential Quality and Affordability Initiative (QAI) projects
• Track project timelines and develop a comprehensive tracker for ongoing projects
• Facilitate multidisciplinary and cross departmental collaboration for project management and QAI development
• Lead routine meetings to ensure alignment and progress on projects
• Develop tools to improve efficiency and automate tasks

Medical Affairs Operations 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, 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

Registered Nurse (RN) Clinical Care Manager

• Provide prior authorization medical reviews, consultation and clinical review services
• Participate in peer-to-peer discussions
• Provide provider education, training, data sharing, performance evaluations and orientation to the plan
• Conduct clinical reviews for designated CareSource members as requested
• Provide physician review for clinical appeals cases
• Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
• Participate in development of policies and procedures
• Participates in quality improvement initiatives, case management activities and member safety activities (i.e. incident management)
• Provide cross-coverage for other Medical Directors and/or markets, as needed
• Oversight and quality improvement activities associated with case management activities
• Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate
• 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
• Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
• Perform any other job related instructions, as requested

Compliance

• Responsible for supporting the establishment of a baseline compliance risk
• Identification of areas of potential exposure
• Development and alignment of compliance risk management strategies with CareSource goals and objectives
• Execution of the compliance program ensuring consistency
• Partner with Business Units and internal support functions to help ensure that all compliance requirements have been met
• Remain current in federal/state laws and regulations regarding Medicaid, Medicare and Marketplace requirements as applicable
• Assist with the creation and execution of the annual compliance work plan, risk assessment activities
• Manage and drive usage for the compliance tracking systems
• Report key statistics and trends of core compliance and oversight functions
• Perform data analysis and reporting activities
• Collaborate with internal resources on the production and communication of compliance related alerts, newsletters and educational materials
• Establish effective working relationships and build credibility within the organization

Manager, Compliance

Risk

• Lead enterprise vendor governance strategy and execution to enable compliant, high-performing third-party partnerships
• Design and enhance governance frameworks, policies, and controls
• Partner with cross-functional leaders to support new business and partnership growth
• Monitor and operationalize regulatory and compliance change and support vendor programs
• Drive continuous improvement of vendor governance processes, tools, and performance metrics
• Provide leadership for the Vendor Workstream within the Vendor Disability Advocacy Council
• Drive completion of playbook deliverables within defined timelines by orchestrating cross-functional workstreams
• Represent Vendor Governance in routine forums and enterprise committees