CareSource

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.

Registered Nurse Care Manager

Compliance

• Oversee activities of the Regulatory Affairs Department
• Lead projects involving government audits and surveys
• Oversee provider contracting including letters of agreement
• Manage communications with OTDA and submit reports
• Lead activities of the Special Investigation Unit (SIU)
• Review and update compliance materials including manuals and policies
• Provide guidance and direction to Department staff

Regulatory Affairs Director

• The Care 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, natural supports and the population with culturally competent delivery of care, services and supports.
• Facilitates communication, coordinates care and service of the member through assessments, identification, person-centered planning, assist the member in creation and evaluation of person-centered care plans to prioritize and address what matters most, behavioral, physical and social determinants of health needs with the aim to improve the of lives our members.
• Engage the member and their natural support system through strength-based assessments and a trauma-informed care approach using motivation interviewing to complete health and psychosocial assessments.
• Facilitate regularly scheduled inter-disciplinary care team (ICT) meetings to meet the needs of the member.
• Educate the member/natural supports about treatment options, community resources, insurance benefits, etc. so that timely and informed decisions can be made.
• Monitor and promote effective utilization of healthcare resources.
• Document care coordination activities and member response in a timely manner according to standards of practice and CareSource policies regarding professional documentation.

Care Manager – Transitions of Care

Attorney

• Assist in preparation and review of various documents on a wide range of topics related to health care law such as: HIPAA, regulatory compliance, Medicaid and Medicare issues, privacy rights and filings related to regulatory requirements
• Participate in research projects on issues impacting CareSource and the health insurance and managed care industry
• Draft, review and edit a variety of legal documents
• Assist in process improvement identification and solutions
• Attend meetings and work closely with members of both the legal and business teams
• Work on assignments geared towards issue-spotting and problem-solving
• Perform any other job-related functions as requested

Legal Intern

• Lead activities of the Regulatory Affairs Department
• Review, draft, negotiate and process agreements and amendments
• Lead projects involving government audits, surveys and requests
• Oversee provider contracting and credentialing process
• Review and update applicable HIPAA policies
• Manage Special Investigation Unit (SIU) activities
• Provide guidance and direction to Department staff

Backend Engineer

• Define and oversee the architecture for Generative AI platforms
• Design and develop complex software systems
• Develop and maintain a strong understanding of modern generative AI tools and concepts
• Rapid development of proof of concepts to evaluate new technology
• Drive innovation and teamwork in a fast-paced environment
• Collaborate with leadership to systematically evaluate currently deployed services
• Apply creative thinking in problem solving and optimizing delivery
• Provide accurate and timely progress updates to project stakeholders
• Stay up to date with the latest industry trends and technologies

AI Python Engineer II

• Manage value-based reimbursement programs within an assigned market or product
• Ensure accurate and timely implementation of new Value Based health partner contracts
• Review Alternative Payment Model (APM) reports for accuracy
• Oversee multidisciplinary implementation of complex reimbursement relationships
• Monitor and assess customized plans for quality or financial goal changes
• Work with internal stakeholders and leadership to coordinate APM program development
• Develop enhanced APM Program reporting for assigned market

Health Partner Incentive Manager

Medical Director

• Responsible for the overall safety of patients with a BH diagnosis, with a special focus on safe prescribing
• Support Ohio Behavioral Health Market team program design and development and strengthening community collaboration
• Supervise part time Behavioral Health Medical Directors
• Serve as the clinical lead in developing and implementing evidenced based clinical policies and practices
• Assume key role in quality improvement initiatives, case management activities and member safety activities
• Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
• Provide provider education, training, data sharing, performance evaluations and orientation to the plan
• 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
• 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 evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
• Provide cross-coverage for other Medical Directors and/or markets, as needed
• Provide prior authorization medical reviews, consultation, and clinical review services
• Conduct clinical reviews for designated CareSource members
• Identify utilization management trends and take appropriate action
• Support market provider network development and maintenance Clinical Appeals
• Participate in peer-to-peer discussions
• Support staff by providing training, clinical consultation, and clinical case review for members
• Perform any other job duties as requested

Enterprise Medical Director – Behavioral Health

• Provide training, clinical consultation, and clinical case reviews for staff
• Participate in peer-to-peer discussions
• Provide provider education, training and performance evaluations
• Participate in development of policies and procedures
• Conduct prior authorization medical reviews and consultations
• Support regulatory and accreditation functions

Associate Behavioral Health Medical Director

Risk

• Oversee the Quality Risk Adjustment (QRA) Medical Record Review (MRR) program
• Lead and manage the MRR Team, providing guidance, training, and support
• Develop and implement strategic plans to optimize risk adjustment processes
• Manage outsourced vendors to execute operational production plan goals
• Establish and maintain MRR quality assurance protocols
• Conduct regular audits and assessments of MRR team’s work
• Research technological solutions such as AI and NLP for data collection
• Collaborate with Data Science, Sourcing, IT, and other stakeholders
• Identify opportunities for process improvements
• Monitor key performance indicators related to risk adjustment and quality metrics.

Senior Manager, Quality Risk Adjustment – Health Plan/MCO Experienced

Affiliate Manager

• Provide high-level administrative support, data management, and operational coordination to the Health Partner Engagement team.
• Maintain accuracy of electronic provider records, profiles, and demographics within databases.
• Provide direct support to providers regarding portal navigation and troubleshooting.
• Support Health Partner Engagement (HPE) team in maintaining and developing key relationships.
• Manage the HPE mailbox for provider and internal stakeholder inquiries and responses.
• Submit and track ServiceNow (SNOW) tickets to resolution and provide necessary follow-up to HPE team.
• Act as the HPLC liaison, providing support for provider credentialing, onboarding, and documentation.
• Work collaboratively with departmental staff and management personnel to ensure continuous performance improvement for provider satisfaction and internal operations.
• Pull and analyze provider claims trend data from Power BI to support provider education needs.
• Create, maintain, and update interactive Power BI dashboards specific to Market.
• Liaise with the MLSS team to access databases, and present data insights to HPE team and leadership.
• Assist in documenting provider concerns in applicable systems and provide support to resolve identified issues and potential risk.
• Perform all necessary duties to successfully support CareSource and Affiliate Companies contractual requirements with state and any other regulatory entities.
• Perform any other job related duties as requested.

Health Partner Engagement Coordinator III

Vice President

• The Associate Vice President, Network and Contracting is responsible for the planning, execution, and strategic plan to build hospital, provider and ancillary provider contracting.
• Oversee Provider’s Contracting and Network operational strategy for assigned market.
• Develops and maintains a market-specific Provider Reimbursement Strategy.
• Establish and sustain relationships with regulatory agencies and other stakeholders to create competitive advantages.
• Oversee complex contracts and negotiations for reimbursements with hospitals and other providers.

AVP, Network and Contracting

Financial Planning and Analysis

• Responsible for compiling and analyzing financial information
• Prepare and review integrated financial analysis and reports to management
• Responsible for analyzing financial trends, costs, revenues, financial commitments and obligations incurred to predict future revenues and expenses
• Responsible for the development of expense projections to support forecast and budget and monitor monthly variances to identify trends
• Lead implementation of new financial reporting procedures for new programs or program changes
• Support quarterly review, forecast process, and annual budget process within Corporate Finance

Registered Nurse Care Manager

Regulatory Affairs Director

Care Manager – Transitions of Care

Legal Intern

Regulatory Affairs Director

AI Python Engineer II

Health Partner Incentive Manager

Enterprise Medical Director – Behavioral Health

Associate Behavioral Health Medical Director

Senior Manager, Quality Risk Adjustment – Health Plan/MCO Experienced

Health Partner Engagement Coordinator III

AVP, Network and Contracting

Financial Planning Analyst III