CareSource

Customer Support

• Ensure quantitative and qualitative objectives are used to meet performance objectives
• Manage staffing and scheduling functions
• Compile reports and departmental communications
• Participate in strategic planning and recommendation of action plans
• Interface with team leaders on effective people management strategies such as staffing, coaching and mentoring
• Lead/participate in strategic department/company projects
• Recommend process improvements
• Maintain positive relationship with internal and external customers
• Perform any other job duties as requested

Manager, Customer Care

Community Manager

• Develop, direct and oversee CareSource MyCare HCBS Waiver and Long-Term Care Services and Supports (LTSS) case management programs
• Assure quality and consistency of MyCare HCBS Waiver care management activities delivered by CareSource staff, delegates, external partners, and contracted vendors
• Develop and provide input to align internal policies, procedures, and goals regarding MyCare HCBS Waiver programs
• Collaborate with the AVP of Integrated Health, assuming responsibility for overall function, operational, clinical, and professional growth of MyCare HCBS Waiver services program
• Establish a team culture that drives excellence in member experience, operations, and quality
• Support Health Services programs by contributing to policies, programs, accreditation, cost, and quality activities relative to MyCare HCBS Waiver program
• Lead the fiscal and regulatory management of MyCare HCBS Waiver Programs
• Ensure high quality case management is delivered within product lines including MyCare Waiver and LTSS services
• Implement and oversee all clinical/care management functions for individuals receiving MyCare HCBS Waiver services
• Manage care management services for CareSource MyCare HCBS Waiver
• Ensure compliance with all contracts, statutes and regulations
• Collaborate with internal/delegate Care Management staff ongoing and share/implement best practices
• Create and monitor MyCare HCBS Waiver work plan

Director, MyCare HCBS Waiver – Preferred Experience with LTSS, Community Based Services, Medicaid, Waivers/Authorizations

Risk

• Overseeing the Quality Risk Adjustment (QRA) Medical Record Review (MRR) program
• Lead and manage the MRR Team
• Develop and implement strategic plans to optimize risk adjustment processes
• Manage outsourced vendors to execute operational production plan goals
• Work with QRA Compliance Team to establish and maintain MRR quality assurance protocols
• Conduct regular audits and assessments of MRR team’s work
• Research technological solutions such as the use of AI and NLP
• Collaborate with various teams to deploy AI/NLP solutions
• Improve insourced retrieval and outsourced vendor work flows
• Develop and implement training programs for staff
• Monitor key performance indicators (KPIs) related to risk adjustment and quality metrics

Senior Manager, Quality Risk Adjustment

Architect

• Strategically provides solutions for the design and implementation of in-house information systems
• Design solutions based on business outcomes
• Create detailed technical requirements to achieve business outcomes
• Oversee and guide delivery teams across components of the solution
• Produce scalable, highly available solutions
• Drive delivery in an agile environment
• Provide overall architecture guidance, governance, and recommendations in support of technical objectives
• Facilitate overall analysis, design, artifacts, and technical requirements validation for strategic initiatives
• Lead / participate in vendor architecture related assessments and reviews

Facets Architect, Level III

Operations

• Guide and direct successful completion of daily tasks
• Prioritize all work, requests and activities
• Escalate any area of significant resource contention along with recommendation for resolution
• Track issues and status to ensure proper follow-up
• Update projects that Application Development is involved with
• Identify root cause of staff issues and appropriate pro-active resolution
• Support a professional relationship between key business stakeholders and Operations Technology teams
• Work closely with customers, business partners, project managers, and team members to understand business requirements
• Assist in the team’s execution of planned and carryover work
• Develop efficient processes to enable teams to achieve quality/efficient delivery
• Support business decisions required by technology
• Participate in departmental meetings/activities and contribute to a collaborative team environment
• Responsible for onboarding, training, and development of staff

Team Lead, Operations Application Development – Facets Dev

Project Manager

• Responsible for successful delivery of project
• Ensure project milestone deliverables are completed and approved at every stage of the project lifecycle
• Assist with the continuous improvement of project management best practices, processes, and tools
• Responsible for ensuring project closure activities are completed
• Lead stakeholders in the refinement of the project charter if applicable
• Work with manager and collaborate with business owners on the identification and assignment of business resources
• Develop and maintain project schedule and WBS
• Work with manager and collaborate with IT point of contact on the identification and assignment of IT resources
• Work with manager to develop project resource plan including forecasting of EPMO FTEs and contractors
• Schedule project audits and ensure compliance to EPMO Governance audit requirements
• Develop and maintain project budget if applicable
• Capture and consolidate EPMO, IT, and business estimates for the Project
• Assess, manage, and control project scope, schedule, and budget change impacts
• Escalate issues to Business Owner, Program Manager, and EPMO Leadership as applicable
• Maintain project stakeholder matrix
• Drive cross-functional communication between impacted business and IT areas
• Work with Talent Development and Communications to develop project communication and training plans
• Schedule and facilitate project meetings including weekly status meetings and stakeholder meetings
• Work with Manager to represent project in program meetings or in Portfolio Governance meetings
• Capture and report on meeting notes, decisions, and action items
• Accurately track and report project status against plan to stakeholders at all levels
• Track, compile and report project metrics and budget
• Advocate for and adhere to EPMO standards, tools and processes
• Work with manager to implement mitigation strategies, contingency plans, and communicate/escalate to stakeholders
• Maintain RAID for project items
• Identify, log, assign and manage risks and issues
• Maintain project SharePoint site and project document repository
• Produce detailed reports, business decision documents, meeting minutes, and notification on assigned projects
• Work with Manager to develop project operations and support plan.

• Responsible for the definition, oversight, coordination and development of Application Solutions, along with the related road maps and lifecycle management.
• Provide architectural guidance for the team to keep solutions consistent, reusable and scalable in the team.
• Work with leadership on opportunities to enhance architecture in the team for the growth initiatives of the company.
• Review designs, provide suggestions on consistency and efficiency.
• Review code for enforcing architectural patterns and best practices.
• Have an overall understanding of the teams’ work end to end, upstream and downstream from the team as well, to enable a complete solution creation by the team.
• Create proof of concepts, tools and utilities for the team’s usage to reduce time spent on repetitive tasks.
• Act as a consultant for the team for current functionality, solution discussions and future enhancements of code.
• Track the performance of teams’ code to assess the current and future load on infrastructure to proactively propose enhancements.
• Create process flows, maintain and present them to leadership and share them with other teams in the organization.
• Lead and represent the team in solution discussions from the incoming work to create reusable modules (ex: services) for the enterprise usage.
• Perform any other job duties as requested.

Facets Application Architect II – Healthcare/Provider

AI Engineer

• Design, configure, test, and deploy AI-enablement applications using low-code/no-code platforms.
• Develop intuitive user interfaces that expose AI capabilities—including generative, agentic, and NLP-based intelligence—to business and operational teams.
• Translate model outputs into business workflows, integrating with existing platforms and use cases.
• Collaborate with data engineers and data scientists to transition solutions from analytical environments (e.g., Databricks) into production.
• Develop Python and SQL logic to support automation, orchestration, and system integration where low-code tools are insufficient.
• Conduct application performance testing and troubleshooting efforts to enhance reliability.
• Ensure application solutions meet usability, accessibility, compliance, and performance standards.
• Develop within Agile and iterative methodologies with rapid prototyping and feedback incorporation.
• Support deployment activities and incident management as needed.
• Work across IT, platform architecture, and analytics teams to ensure smooth production deployment.
• Perform any other job related duties as requested.

Data Solutions AI Application Developer III

• Execute and support the tasks to develop, implement and maintain reimbursement guidelines for assigned CareSource Products
• Collaborate with key stakeholders and Product to ensure Claims Reimbursement process and procedures align with the overall strategy
• Participate in Benefit Interpretation support
• Support required legislative and regulatory reviews
• Assist in the tasks to support the established budgets, timelines and task schedules
• Execute assigned tasks to collaborate with senior leadership

Claims Operations

Manager

• 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
• Facilitates communication, coordinates care and service of the member through assessments
• 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
• Educates the member/natural supports about treatment options, community resources, insurance benefits, etc.
• Monitors and promotes effective utilization of healthcare resources through clinical variance and benefits management
• Completes psychosocial and behavioral assessments
• Collaborates with facility-based healthcare professionals and providers to plan for post-discharge care needs

Care Manager

Medical Director

• The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members.
• 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

Medical Director – Appeals, Managed Care, Family Medicine

Analyst

• Leads and defines system requirements associated with Member Benefits, Provider Reimbursement and payment systems
• Identify, manage and document the status of open issues
• Develop and utilize reports to analyze and stratify data
• Plan/implement new software releases including testing and training
• Serve as liaison between IT and business areas
• Lead review of benefits or provider reimbursement
• Lead in the development and execution of test plans and scenarios
• Audit configuration to ensure accuracy and minimize fraud and abuse

Configuration System Analyst II – Facets, Benefits Configuration

Program Manager

• Responsible for successful delivery of LTSS and Dual Eligible programs
• Understand the LTSS and Dual Eligible programs to ensure effective cross functional coordination throughout the organization
• Ensure program milestone deliverables are completed and approved at every stage of the program lifecycle
• Assist with the continuous improvement of program/project management best practices, processes, and tools
• Maintain program stakeholder matrix and drive cross-functional communication between impacted business
• Collaborate with functional owners on the identification and assignment of resources
• Capture and consolidate LTSS Program KPIs and assess, manage, and control program scope, schedule, and change impacts
• Identify, log, and manage risk, implement mitigation strategies, and communicate to stakeholders

LTSS & Dual Eligible Program Manager

Auditor

• Responsible for performing over-reads of vendor ICD-10 coding
• Reviewing provider documentation supplied to them
• Validates the accurateness of ICD-10 codes assigned by the vendor
• Tracks the trends and reports on the findings
• Demonstrates a thorough understanding of Risk Adjustment hierarchical condition categories (HCCs)
• Participates in quality coding initiatives as appropriate or assigned
• Maintains knowledge of AHA Coding Clinic and ICD-10 Official Guidelines for Coding and Reporting
• May be asked to perform over reads of provider coding/documentation
• Meets deadlines and works independently on multiple projects

Risk Adjustment Coding Auditor II, AAPC or AHIMA coding certification required

• The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members.
• 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
• Collaborate with market/product leaders to help define market strategy
• 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