CareSource

Medical Billing and Coding

• Analyze medical records and supplemental data to ensure diagnostic and procedural codes accurately reflect and support the visit as it relates to correct coding guidelines and medical necessity
• Lead the identification of root causes of claims issues
• Hold vendors and internal CareSource teams accountable in implementing process improvements
• Audit and interpret medical procedures and terminology in medical documentation
• Utilize critical thinking skills, discretion and independent judgment to determine best course of action for each inquiry
• Identify root cause of vendor payment issues
• Lead solutioning sessions with vendor and internal CareSource teams
• Conduct audits of vendor medical records
• Assess and generate reports to determine claim impact to aid in resolution
• Collaborate with leadership to advocate resolving issues based on industry standard coding practices
• Act as a subject matter expert to analyze and decide the appropriate reimbursement for codes submitted on claims
• Track status and oversee the work to conclusion as it moves through vendor and internal teams
• Develop claims test case scenarios and test plans to ensure industry standard coding practices are implemented
• Conduct on-going monitoring and communications to promote and ensure adherence to established protocols and best practices
• Build and maintain cross-functional working relationships with operational departments, markets, and Quality leaders
• Maintain an understanding of Federal and State Regulatory requirements
• Interface with vendor and represent CareSource in a professional manner
• Assist the vendors proactively by evaluating risks and developing risk-mitigation actions

Vendor Medical Coding Analyst

Manager

• 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.
• Assesses, plans and provides continuous care management across all venues of care, including hospital, sub-acute, long-term and home settings.
• 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.
• Documents any grievance according to plan policy.
• 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.
• Perform any other job related duties as requested.

Behavioral Health Registered Nurse (RN) Care Manager

Medical Director

• Responsible for the implementation of market-level clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards
• Support staff by providing training, clinical consultation, and clinical case review for members
• Participate in Interdisciplinary Care Team meetings, Inpatient Census Rounds and other clinical meetings
• Support market provider network development and maintenance
• Provides leadership to direct reports to achieve market goals
• Participate in peer-to-peer discussions
• Conduct quality of care reviews

Market Chief Medical Director, Michigan Licensure

Consultant

• Conduct assessments to identify the unique needs of breastfeeding mothers engaged in the Mom and Baby Beginnings or NICU CM programs
• Provide individualized education and support and develop tailored care plans to address challenges related to breastfeeding
• Engage members and their support systems using strength-based assessments and a trauma-informed care approach
• Facilitate regular interdisciplinary care team (ICT) meetings to address member needs
• Develop and regularly update a person-centered individualized care plan (ICP)
• Identify and manage barriers to achieving care plan goals and implement effective interventions based on clinical standards

Lactation Consultant, RN

Artificial Intelligence

• Partner with senior business executives to identify, shape, and refine AI use cases aligned to strategic objectives
• Translate business problems into execution ready AI initiatives
• Drive speed to value by standardizing reusable AI patterns, playbooks, and deployment accelerators
• Lead the AI enablement function across verticals
• Establish repeatable "AI pod" execution models that integrate various resources
• Ensure consistent adoption of ATO tools, platforms, and ways of working across the enterprise
• Serve as a trusted AI execution partner to functional leaders
• Drive AI literacy and adoption in collaboration with HR and functional leadership
• Act as a visible leader and advocate for AI first ways of working

Vice President – Enterprise AI Transformation

Customer Support

• Assist members/beneficiaries or providers with routine service inquiries
• Resolve member/beneficiaries or provider routine service inquiries including claims processing and member benefit education
• Ensure adherence to HIPAA and state/federal requirements/regulations
• Research, follow up, and resolve open/pending issues promptly
• Build and strengthen member or provider relationships through quality customer service
• Maintain knowledge of all processes and procedures
• Act as a mentor to new hire employees

Customer Care Specialist, Contractors

• Responsible for the implementation of market-level clinical care standards and practice guidelines
• Support staff by providing training, clinical consultation, and clinical case review
• Participate in Interdisciplinary Care Team meetings, Inpatient Census Rounds and other clinical meetings
• Support market provider network development and maintenance
• Provide leadership to direct reports to achieve market goals
• Participation in market level quality initiatives and community collaboratives
• Conduct quality of care reviews and support regulatory and accreditation functions

Market Chief Medical Director, Michigan

Community Manager

• Collaborates with members of an inter-disciplinary care team (ICT), providers, community and faith-based organizations
• Facilitates communication, coordinates care and service of the member through assessments
• Develops and regularly updates a person-centered individualized care plan (ICP)
• Identifies and manages barriers to achievement of care plan goals
• Assists with empowering the member to manage and improve their health
• Educates the member/ natural supports about treatment options, community resources, insurance benefits
• Facilitates coordination, communication and collaboration with the member the ICT
• Verify eligibility, previous enrollment history, demographics and current health status of each member
• Completes psychosocial and behavioral assessments
• Oversees timely psychosocial and behavioral assessments and the care planning
• Documents care coordination activities and member response in a timely manner.

Community Based Care Manager – RN

QA Automation Engineer

• Collaborate with cross-functional teams to identify areas for intelligent/ robotic process automation and AI/ ML applications
• Gather and define requirements for AI/ML and automation projects
• Analyze and preprocess data for AI/ML model development; establish data pipelines
• Implement opportunities for process automation using RPA and IPA; create and maintain workflows
• Monitor performance of AI/ML models and solutions; iterate on improvements
• Ensure integration of AI/ML and automation solutions into existing systems
• Provide training and support to end-users interacting with AI/ML models or automated systems
• Assist in documenting software requirements and specifications
• Lead development projects and coordinate activities with developer teams
• Perform technical code reviews

Intelligent Automation Developer II – UiPath, Agentic AI

AI Research Scientist

• The Applied AI Scientist III is responsible for developing advanced analytics solutions using AI technologies to enhance healthcare operations.
• Evaluate emerging technology and integrate advancements into projects to drive innovation.
• Utilize NLP algorithms and deep learning techniques to analyze unstructured healthcare data.
• Lead development from prototype through production in partnership with engineering.
• Collaborate with interdisciplinary teams to identify opportunities for data-driven solutions.

Applied AI Scientist – III

Risk

• Responsible for the day-to-day operations of the risk adjustment function across all lines of business
• Analyzes member information to ensure the Risk Adjustment Factor accurately reflects the membership health profile
• Develops and implements processes and procedures to ensure the accuracy and completeness of the Medicare Risk Adjustment, Medicaid and ACA/Marketplace data
• Analyzes and monitors clinical Risk Adjustment reports
• Supports the development of monthly revenue accruals and forecast related to the risk adjustment activities
• Oversees and monitors data submission for attestation to CMS for Risk Adjustment
• Recruits, develops, and motivates staff

Senior Manager, Medical Risk Adjustment Analytics

• Leads the execution of enterprise clinical data governance and integration strategies
• Establish and maintain a comprehensive clinical data inventory inclusive of data sources, attributes, ingestion pathways, ownership, downstream use cases, and refresh cadence
• Develop and maintain standardized business requirement templates for clinical data acquisition
• Oversee governance activities related to acquisition opportunities and data quality performance, ensuring effective documentation, risk escalation, and decision-making
• Identifies and recommends clinical data acquisition opportunities by reviewing emerging trends, regulatory changes, and competitive intelligence
• Drive clinical data use cases from concept through implementation — including business case development, requirements definition, technical coordination, testing, deployment, value tracking, and post-implementation optimization
• Partner with Enterprise IT and Data Engineering to prioritize ingestion pipelines and interoperability enhancements (e.g., HL7/FHIR)
• Oversees performance monitoring related to clinical data vendors
• Ensure governance guardrails are maintained to prevent fragmented, duplicative, or misaligned clinical data acquisition efforts across business units
• Serve as liaison between business domains and enterprise governance forums to ensure alignment with broader enterprise data strategy
• Lead and develop a team of analysts responsible for data profiling, reconciliation, acquisition evaluation, quality monitoring, and roadmap support.

Senior Director, Clinical Data Governance, Integration

IT Support

• Conduct retrospective and targeted audits of utilization management medical necessity determinations including pre-service, concurrent, and post service reviews.
• Evaluate application of evidence-based clinical criteria (MCG, InterQual) and adherence to medical and administrative policies in utilization management determinations.
• Assess clinical documentation, rationale for determinations, and compliance with regulatory and contractual and accreditation requirements.
• Analyze audit findings to identify trends, inconsistencies, and systemic issues in medical necessity decision-making and utilization management processes.
• Prepare comprehensive audit reports summarizing findings, identified risks, and recommendations for corrective action and process improvement to leadership.
• Collaborate with Medical Directors, UM leadership and UM Operational teams to address complex audit findings.
• Participate in policy review and process improvement initiatives to strengthen the accuracy, consistency, and defensibility of medical necessity determinations.

Clinical Audit Specialist – Utilization Management

Vice President

• Provides strategic leadership and enterprise oversight for Utilization Management review activities and initiatives
• Accountable for executing UM strategy and driving sustained operational performance
• Ensure effective alignment and integration of people, processes, and systems
• Manage execution of meeting or exceeding clinical operation requirements by Federal, State, and Accrediting bodies
• Collaborate to build necessary divisional market infrastructure and matrix support
• Develop and monitor UM policies, procedures and goals as needed to align with regulatory and accreditation requirements