CareSource

Actuary

• Provide leadership and direction to ensure team goals and strategies are successfully achieved
• Responsible for pricing, forecasting, reserving or other actuarial processes including development of key assumptions, evaluation of financial experience and trend drivers
• Develop and communicate actionable and strategic recommendations to leadership in support of company goals
• Manage the development and maintenance of actuarial models to support key business goals and initiatives, such as actual to expected experience reporting, actuarial reserves and accruals, bid pricing/rate filings, forecasting, and contracting models
• Own the actuarial processes being managed (i.e., rate/bid filings, pricing, forecasting, reserving) within the company and with external vendors for assigned lines of business
• Perform any other job related instructions as requested

Managing Actuary, Medicaid Rate Advocacy

Analytics Engineer

• Develop end-to-end data warehouse / data mart solutions, utilizing Databricks and Microsoft technologies.
• Patterns include traditional dimensional modeling (Kimball), and schema-less (big data) models.
• Develop data modeling expertise on one or more insurance-specific data / workflows, such as claims, care management (CM), utilization management (UM), eligibility, and population health.
• Partner with Data Solutions Analysts, and line-of-business stakeholders in product ideation, requirements gathering, data reviews, ongoing data quality, and troubleshooting.
• Develop or support reports, dashboards, and ad-hoc analysis supporting business consumers.
• Test, debug, and performance tune data pipelines and end-user queries.
• Maintain the highest level of data security and confidentiality, conforming to all HIPAA and contract requirements.
• Perform any other job duties as requested.

Data Solutions Engineer II

Manager

• Engage with the enrollee in their homes and other community settings
• Function as a liaison between healthcare providers, community resources, and enrollees
• Perform required assessments on a timely basis
• Engage enrollees in care plan development and implementation
• Lead the interdisciplinary care team (ICT)
• Oversee enrollee utilization of long-term services and supports
• Assist members in accessing community resources
• Educate members about their benefits and available services
• Promote healthy lifestyle choices and self-management strategies
• Follow up with members after hospitalizations or significant health events
• Advocate for the needs and preferences of enrollees within the healthcare system

Registered Nurse (RN), Clinical Care Manager

• 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

BH Clinical Care Manager, LMHC or LICSW

• Provide monitoring, follow-up, and clinical care management to dually-eligible enrollees
• Engage with enrollees in their homes and community settings
• Function as a liaison between healthcare providers, community resources, and enrollees
• Perform required assessments on a timely basis
• Lead the interdisciplinary care team to create holistic care plans
• Oversee enrollee utilization of long-term services and supports
• Assist members in accessing community resources
• Educate members about benefits and available services
• Promote healthy lifestyle choices and self-management strategies
• Follow up with members after hospitalizations to ensure continuity of care
• Advocate for the needs and preferences of enrollees

Clinical Care Manager, LICSW/LMHC

• 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
• Engage enrollees in care plan development and implementation
• Lead the interdisciplinary care team (ICT) and collaborate with peers both internal and external to the organization
• Oversee enrollee utilization of long-term services and supports
• Assist members in accessing community resources
• Educate members about their benefits and available services under both Medicare and Medicaid
• Promote healthy lifestyle choices and self-management strategies
• Follow up with members after hospitalizations or significant health events
• Report abuse, neglect, or exploitation of older adults and adults with disabilities as a mandated reporter as required by State law.

Customer Success Manager

• Provide strategic and operational leadership for the Medical Management function across UM, CM, BH, PH, CQM, and Pharmacy
• Oversee utilization management activities
• Oversee prior authorization processes, benefit and service determinations
• Ensure effective case management services
• Lead population health strategies
• Oversee behavioral health integration and coordination with medical and case management operations
• Ensure compliance, performance monitoring, and reporting for clinical quality and pharmacy management programs
• Ensure timely and accurate completion of all Government-required medical management deliverables

Medical Management Director – CSMV, Managed Care & TRICARE Experience Preferred

• Conducts outreach to members and providers to confirm service details
• Coordinate services by working with providers, community partners, and member/caregivers
• Serves as a support resource for member and provider requests
• Collaborates with the care team, providers, and other partners
• Initiate outreach to members, vendors, providers, and/or vendors/suppliers
• Provide administrative support as assigned
• Assist members and the Care Team with solving health plan related concerns
• Help members schedule transportation to medical appointments
• Support targeted member outreach campaigns
• Coordinates interpreting and translation supporting services for the member
• Obtain documents/forms that allow Care Team to speak with members and/or representatives
• Assist leadership with the development, refinement and enhancement of programs
• Mentor for new Care Navigation Specialist
• Maintain accurate documentation and maintenance of member records
• Follow established standards of practice, internal policies, and procedures
• Identify member and provider needs and facilitates referrals

Registered Nurse (RN) Clinical Care Manager, Middleboro

• Conducts outreach to members and providers to confirm service details, coordinate scheduling, address general inquiries, and ensure accurate documentation of care coordination activities.
• Coordinate services by working with providers, community partners, and member/caregivers to manage scheduling, service updates, and administrative changes, as needed.
• Serves as a support resource for member and provider requests, escalations, or concerns by coordinating responses and ensuring issues are routed or addressed promptly.
• Collaborates with the care team, providers, and other partners as needed to support member service requests and ensure smooth communication and continuity across care activities.
• Initiate outreach to members, vendors, providers, and/or vendors/suppliers to follow up on non-clinical matters assigned by the Care Team (e.g., including authorization status, DME status, appointment scheduling and prescription assistance).
• Provide administrative support as assigned.
• Assist members and the Care Team with solving health plan related concerns, i.e. claims follow up or prior auth status, etc.
• Help members schedule transportation to medical appointments; assist members with booking issues.
• Support targeted member outreach campaigns when there is an event that has the potential to broadly impact our membership’s wellness, such as agency closures, hazardous/catastrophic events (e.g., power outages, fires, inundations).
• Coordinates interpreting and translation supporting services for the member (including ADA compliance).
• Obtain documents/forms that allow Care Team to speak with members and/or representatives on the member’s behalf in accordance with HIPAA laws – e.g., Release of Information (ROI), Oral Disclosure of Protected Health Information.
• Assist leadership with the development, refinement and enhancement of programs, initiatives, processes, policies, workflows, and projects.
• Mentor for new Care Navigation Specialist – during and beyond their orientation period, if needed.
• Maintain accurate documentation and maintenance of member records and alignment with regulatory standards, ensuring timely distribution to appropriate internal teams or provider partners as needed.
• Follow established standards of practice, internal policies, and procedures to ensure compliance with contractual obligations and applicable regulatory requirements.
• Identify member and provider needs and facilitates referrals to appropriate internal teams such as care management or community-based support programs.
• Performs any other job related duties as requested.

Data Scientist

• The Manager, Predictive Analytics and Data Science is responsible for serving as the leader, subject matter expert, teacher, and mentor of the Predictive Analytics and Data Science team.
• Lead a team of data scientists and analysts to develop and execute predictive analytics projects and initiatives
• Collaborate with cross-functional teams, including IT, healthcare operations, finance, and clinical teams, to identify opportunities for data-driven solutions and predictive modeling applications
• Develop and implement predictive models, algorithms, and statistical techniques to extract insights from large and complex healthcare datasets
• Utilize machine learning algorithms to identify patterns, trends, and opportunities for improving operational efficiency, cost containment, and patient care
• Utilize Natural Language Processing (NLP) algorithms and techniques to process and analyze unstructured healthcare data, such as clinical notes, patient feedback, and medical literature, to extract meaningful insights
• Conduct rigorous data analysis, including data cleansing, feature engineering, and exploratory data analysis, to derive meaningful insights and actionable recommendations
• Stay abreast of emerging trends, tools, and techniques in predictive analytics, data science, and healthcare informatics to drive innovation and continuous improvement
• Collaborate with stakeholders to define key performance indicators (KPIs), develop metrics, and create dashboards and reports that effectively communicate insights and support decision-making
• Provide strategic guidance and recommendations to senior leadership based on data analysis and predictive modeling results
• Mentor and develop team members, fostering a collaborative and innovative work environment
• Ensure compliance with data privacy and security regulations and maintain the highest standards of data integrity

Manager, Predictive Analytics, Data Science

Marketing

• Promote Commonwealth Care Alliance's (CCA) health products to individuals and groups
• Execute marketing and enrollment strategies
• Cultivate relationships with contracted sites and health providers
• Perform enrollment-related activities such as screening leads and explaining the program
• Develop a resource map of assigned territory and cultivate relationships

Outreach & Marketing Specialist

Community Manager

• Serve as a single point of contact for assessment and service coordination
• Facilitate the person-Centered planning process and coordinate services
• Consult with members, families, and professionals to discuss health care needs
• Monitor service delivery for appropriateness of care
• Complete psychosocial healthcare questionnaires and behavioral assessments
• Maintain current and accurate documentation of contacts and assessments
• Assist in educating members about their condition and care options
• Conduct regular travel for member and provider visits as needed

Community Based Care Coordinator I

Customer Support

• Assist members/beneficiaries or providers with routine service inquiries
• Resolve member/beneficiaries or provider routine service inquiries
• Ensure all HIPAA, State and/or Federal requirements/regulations are always adhered to
• Research, follow up, and resolve all open/pending issues in a timely manner to ensure member or provider satisfaction
• Build and strengthen member or provider relationships by providing quality customer service
• Maintain knowledge and understanding of all processes and procedures
• Maintain complete and accurate documentation of all telephone and written communications
• Act as a mentor to new hire employees

Customer Care Specialist I

• The Nurse Care Manager is responsible for providing care coordination including in-home assessment, planning, facilitation, advocacy and authorization of covered plan services to meet the member's health needs while promoting quality cost effective outcomes.
• 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, cultural influences, functional and cognitive needs.
• Identifies same day grievances, investigates and documents accordingly.
• Documents care management/coordination according to company policy.

Registered Nurse (RN) Care Manager – Manhattan

• Coordinate the implementation and execution of medical drug strategy and management of the pre-determination process for specialty pharmacy.
• Drive biosimilar adoption, utilization pathways, clear/white bagging policies, specialty pharmacy partnerships, and sourcing strategies.
• Optimize infusion and specialty drug administration settings for cost savings and improved outcomes.
• Lead execution of CMS/state drug requirements across systems and providers, Part B Implementation.
• Lead QAI efforts for medical drug spend and utilization support cost containment and driving medical forecasting for consistent execution.
• Coordinate and collaborate with Pharmacy, Medical, Network, Finance, and Operations to ensure unified execution.
• 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 specialty/medical drug services and programs.
• Interact with providers and staff to manage benefits aligned with regulations, URAC and NCQA regulations and CareSource policies and vision.
• Oversee CQI (Continuous Quality Improvement) activities and document departmental processes for internal and external use.
• Review and revise workflows to maximize efficiencies.
• Monitor productivity and utilization trends.
• Regularly report all specialty pharmacy/medical drug data and program performance.
• 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.
• Perform any other job related duties as requested.

Managing Actuary, Medicaid Rate Advocacy

Data Solutions Engineer II

Registered Nurse (RN), Clinical Care Manager

BH Clinical Care Manager, LMHC or LICSW

Clinical Care Manager, LICSW/LMHC

Registered Nurse (RN), Clinical Care Manager

Medical Management Director – CSMV, Managed Care & TRICARE Experience Preferred

Registered Nurse (RN) Clinical Care Manager, Middleboro

Clinical Care Manager, LICSW/LMHC

Manager, Predictive Analytics, Data Science

Outreach & Marketing Specialist

Community Based Care Coordinator I

Customer Care Specialist I

Registered Nurse (RN) Care Manager – Manhattan

Manager, Medical Drug Strategy – Execution