Guide Healthcare

Compliance

• Supervising and directing the day-to-day operations of the clinical compliance auditors and specialists.
• Serving as the clinical services liaison to senior management and other company leaders and assisting in developing coordinated and efficient companywide team processes.
• Assisting with coordinating orientation, training, continuing education, and ongoing performance monitoring for clinical compliance auditors and other departments as required.
• Working with Leadership to promote staff members’ continued professional growth and education.
• In conjunction with the Compliance Manager, UM Manager, and PHM Manager, overseeing and assisting with developing and managing the agenda and meeting minutes for the monthly utilization management data reported to the Independent Physician Association (IPA) UM Committee.
• Assisting with facilitating UM and PHM Plan development and adherence.
• Identifying UM and PHM Plan requirements and assisting in creating auditing guidelines to ensure clinical staff continue to meet minimum requirements, including quarterly, semiannual, and annual submission requirements set forth in the UM and PHM Plans.
• Serving as a secondary reviewer to ensure adherence to the denial process and all denial compliance audit requirements, reviewing documentation, and ensuring all documentation is submitted in a timely manner.
• Supporting the maintenance of confidentiality related to all computer programs, medical records, and other data.
• Providing critical-thinking skills, decisive judgment, and the ability to work with minimal supervision.
• Ensuring meeting minutes are completed, signed, and uploaded in accordance with UM and PHM Plan requirements.
• Assisting with all internal and external audit reviews and submissions.
• Completing monthly check-ins with clinical compliance auditors and specialists.

Supervisor, Clinical Compliance, RN

Clinical Coordinator

• Work in a fully remote environment and virtually engage with company and team in your daily work.
• Subject Matter Expert (SME) on entire scope of QI measures, services, customers and quality initiatives under various commercial and governmental payers.
• Conduct proactive patient outreach initiatives to identify and address quality gaps, engaging with patients to educate them on preventive care measures, schedule necessary screenings or appointments, and facilitate adherence to treatment plans, thereby contributing to improved health outcomes and closing quality gaps.
• Collect quality data using various methods of data sourcing-EMR, claims, provider outreach.
• Manage daily work using multiple systems and applications-EMR systems, payer portals, vendor platforms, Guidehealth applications, Microsoft 365 for Excel, Word and PowerPoint and Teams for messaging and meetings.
• Work with patient lists, gap lists, sourced health data and medical records in your daily work.
• Leverage all quality related resources to ensure accuracy and completeness of work measure/project instructions, NCQA/HEDIS® specifications, coding documents, quick reference guides.
• Prioritize daily work to meet various quality reporting deadlines and requirements.
• Communicate quality performances, barriers and improvement strategies both internally and with customers.
• Follow all established policies and procedures for various QI workflows to ensure overall success.
• Collaborate w/ customers, payers, co-workers to accomplish daily work.
• Participate in all departmental and payer sponsored webinars/trainings/support calls throughout the year.
• Communicate professionally and develop positive relationships with co-workers, customers, providers and providers’ support staff.

Clinical Quality Improvement Coordinator

Manager

• Building meaningful relationships with patients and families, understanding their goals, barriers, and motivators.
• Creating personalized care plans that go beyond diagnoses, addressing social determinants and emotional well-being.
• Coordinating care across providers and settings, ensuring safety, quality, and continuity.
• Educating and empower members to make informed decisions and navigate the healthcare system confidently.
• Collaborating with an interdisciplinary team, sharing insights and advocating for whole-person health.
• Using data as a tool for insight—not the driver of care—to identify opportunities and measure impact while keeping the patient at the center.
• Maintaining compliance with regulatory standards while prioritizing compassion and connection.

RN Case Manager

General

• Acting as the technical point of contact for both external and internal stakeholders during the onboarding and implementation process.
• Managing, coordinating, and executing data integration and tech integration projects, including EMR integrations, third-party vendor integrations, data retrievals, API connections, and SFTP data feeds with vendors.
• Facilitating conversations between internal and external tech and business stakeholders, designing, documenting and presenting data flow diagrams, and project managing integrations to ensure successful and smooth delivery of the end results.
• Translating clinical and operational requirements into technical configurations and workflows.
• Creating and maintaining integration documentation including technical specifications, workflow and processes diagrams, implementation guides, and SOPs.
• Performing data QA and validation activities, including executing scripts and manual checks for data format, completeness, and accuracy.
• Troubleshooting and resolving integration issues, coordinating with engineering, vendor, or client teams as needed.
• Managing go-live planning, execution, maintenance and provide post-implementation support.

Senior Technical Integration Specialist

Technical Product Manager

• Partner with clinical operations teams (Care Management, Quality, Population Health, Customer Service) to identify, prioritize, and collect requirements for Rose’s use cases.
• Maintain and prioritize use cases, features, and enhancement requests, balancing clinical impact, technical feasibility, and organizational readiness.
• Own the project plan for Rose use cases from requirements through deployment, including timelines, milestones, dependencies, and risk mitigation.
• Ensure timely and clear communication of priorities and activities to leadership and cross-functional partners.
• Analyze performance data to identify trends, surface improvement opportunities, and inform the roadmap.
• Conduct regular call audits to ensure clinical accuracy, HIPAA compliance, appropriate tone, and adherence to approved scripts and conversation flows in partnership with clinical subject matter experts.
• Ensure all use cases comply with applicable healthcare regulations, including HIPAA, CMS, URAC, DiME, and state-specific requirements.
• Facilitate regular program reviews with senior leadership, providing status updates, risk assessments, and strategic recommendations.
• Build strong relationships across the organization to drive adoption and gather continuous feedback.

Customer Success Manager

• Provide friendly, accurate, and timely service to Customers (members/patients, providers, and other stakeholders) through inbound and outbound interactions via phone, email, chat, SMS, video calls, co-browser sessions, and other communication channels.
• Actively listen to understand Customers’ needs and concerns and demonstrate empathy and patience.
• Help Customers navigate internal processes and available resources to achieve their desired results.
• Build rapport and establish trust with Customers to create a positive, personalized experience.
• Go above and beyond to exceed Customer expectations and leave a lasting positive impression.
• Protect Customers’ privacy, dignity, and Personal Health Information (PHI) at all times and comply with HIPAA and all applicable laws and regulations.
• Backup and support other departments (i.e., Claims, UM, Intake, Quality, Care Management, Patient Engagement) and perform a variety of other duties as assigned.
• Issue Resolution and Problem Solving: Answer inquiries regarding benefits, claims, eligibility, provider networks, prior authorizations, preventative health promotion, and other healthcare-related topics.
• Research and resolve complex issues, collaborating with other departments as needed (e.g., Claims, Provider Relations, Utilization Management, Intake, Care Management, Quality, etc.).
• Take ownership of Customer issues, following through to ensure complete resolution and satisfaction.
• Proactively identify and escalate recurring issues or trends to management.
• Document all interactions and resolutions accurately and thoroughly in the appropriate systems.
• Healthcare Consumer Education: Educate Customers on plan benefits, policies, and procedures.
• Clearly and concisely explain complex healthcare information in a way that is easy to understand.
• Encourage the use of our self-service portal and effectively teach Customers how to navigate and use our portal and other available resources.
• Empower Customers with the knowledge they need to make informed decisions about their health and benefits.
• Outbound Outreach and Program Enrollment: Conduct outbound enrollment outreach, inviting eligible members/patients to join Guidehealth’s care management and care coordination programs.
• Conduct outbound clinical quality and wellness outreach, including medication refill reminders, blood pressure check-ins, preventive care reminders, gap-in-care closure, and general wellness check-ins.
• Handle inbound calls from prospective enrollees inquiring about Guidehealth’s care management programs, qualifying interest and guiding them through next steps.
• Clearly articulate the value, features, and benefits of our programs in plain, customer-centered language, helping Customers understand how participation supports their health goals.
• Apply consultative listening and persuasion skills to address hesitation, answer questions, and overcome common objections with empathy, patience, and respect for the Customer’s decision.
• Follow approved scripts, talking points, and call flows while adapting tone and pacing to each individual member.
• Recognize and appropriately escalate clinical and behavioral health concerns, as well as urgent member needs, identified during Customer interactions.
• Comply with all applicable outbound calling regulations and policies, including TCPA, state do-not-call rules, and Guidehealth scripting and disclosure standards. (Note: Customer Guides do not close sales transactions or collect payments; the focus is enrollment, education, and customer engagement.)
• Compliance and Quality: Actively seek and accept coaching, feedback, and opportunities for professional development from peers, Customer Guide Coaches, Trainers, and Managers.
• Adhere to all company policies, procedures, and regulatory requirements (e.g., HIPAA).

Customer Engagement Specialist

• Provide friendly, accurate, and timely service to Customers (members/patients, providers, and other stakeholders) through inbound and outbound interactions via phone, email, chat, SMS, video calls, co-browser sessions, and other communication channels.
• Actively listen to understand Customers’ needs and concerns and demonstrate empathy and patience.
• Help Customers navigate internal processes and available resources to achieve their desired results.
• Build rapport and establish trust with Customers to create a positive, personalized experience.
• Go above and beyond to exceed Customer expectations and leave a lasting positive impression.
• Protect Customers’ privacy, dignity, and Personal Health Information (PHI) at all times and comply with HIPAA and all applicable laws and regulations.
• Backup and support other departments (i.e., Claims, UM, Intake, Quality, Care Management, Patient Engagement) and perform a variety of other duties as assigned.
• Issue Resolution and Problem Solving: Answer inquiries regarding benefits, claims, eligibility, provider networks, prior authorizations, preventative health promotion, and other healthcare-related topics. Research and resolve complex issues, collaborating with other departments as needed (e.g., Claims, Provider Relations, Utilization Management, Intake, Care Management, Quality, etc.). Take ownership of Customer issues, following through to ensure complete resolution and satisfaction. Proactively identify and escalate recurring issues or trends to management. Document all interactions and resolutions accurately and thoroughly in the appropriate systems.
• Research and solve Customer issues and reply to Customer inquiries with friendly, accurate, and timely resolutions.
• Healthcare Consumer Education: Educate Customers on plan benefits, policies, and procedures. Clearly and concisely explain complex healthcare information in a way that is easy to understand. Encourage the use of our self-service portal and effectively teach Customers how to navigate and use our portal and other available resources. Empower Customers with the knowledge they need to make informed decisions about their health and benefits.
• Outbound Outreach and Program Enrollment: Conduct outbound enrollment outreach, inviting eligible members/patients to join Guidehealth’s care management and care coordination programs. Conduct outbound clinical quality and wellness outreach, including medication refill reminders, blood pressure check-ins, preventive care reminders, gap-in-care closure, and general wellness check-ins. Handle inbound calls from prospective enrollees inquiring about Guidehealth’s care management programs, qualifying interest and guiding them through next steps. Clearly articulate the value, features, and benefits of our programs in plain, customer-centered language, helping Customers understand how participation supports their health goals. Apply consultative listening and persuasion skills to address hesitation, answer questions, and overcome common objections with empathy, patience, and respect for the Customer’s decision. Follow approved scripts, talking points, and call flows while adapting tone and pacing to each individual member. Operate effectively within dialer-based outbound workflows, manage call dispositions accurately, and meet outreach productivity and quality targets. Recognize and appropriately escalate clinical and behavioral health concerns, as well as urgent member needs, identified during Customer interactions. Comply with all applicable outbound calling regulations and policies, including TCPA, state do-not-call rules, and Guidehealth scripting and disclosure standards. (Note: Customer Guides do not close sales transactions or collect payments; the focus is enrollment, education, and customer engagement.)
• Compliance and Quality: Actively seek and accept coaching, feedback, and opportunities for professional development from peers, Customer Guide Coaches, Trainers, and Managers. Adhere to all company policies, procedures, and regulatory requirements (e.g., HIPAA). Maintain confidentiality and protect sensitive member information. Meet or exceed individual and team performance goals related to Customer satisfaction (CSAT), first contact resolution, quality, efficiency, attendance, and schedule adherence. Participate in ongoing training and development to enhance skills and knowledge. Contribute thoughtful ideas and suggestions for improvement and promote a positive and collaborative team environment.

Recruitment

• Own full-cycle recruitment for a broad range of clinical and non-clinical roles, from creative talent pipeline development and sourcing through interview coordination, offer negotiation, offer acceptance, pre-boarding and onboarding.
• Quickly build a strong understanding of Guidehealth’s business, operating model, workforce needs, and People processes to develop and execute effective, role-aligned recruiting strategies.
• Partner closely with hiring managers, clinical leaders, and business stakeholders to define candidate profiles, align on hiring priorities, and execute search plans that support business goals.
• Develop and execute creative, investigative, and data-informed sourcing strategies using LinkedIn, job boards, referrals, networking, market outreach, and talent communities.
• Deliver a high-touch, empathy-driven candidate experience that reflects Guidehealth’s patient-centered mission and values, clinical culture, and commitment to people at every touchpoint before and after hire, including regular new-hire check-ins to support a strong onboarding transition.
• Manage pre-boarding activities for hired candidates, including background checks, credential verification, licensure review, and pre-hire documentation, while ensuring strict adherence to employment law, healthcare credentialing regulations, state licensure requirements, and internal compliance standards.
• Proactively identify, escalate, and resolve compliance gaps, hiring risks, bottlenecks, and candidate experience concerns, while maintaining meticulous documentation to support audit readiness and to reduce liability.
• Apply a healthcare-informed lens to candidate assessment, using structured interviews, behavioral-based questions, assessment tools, and sound judgment to evaluate technical capability, interpersonal warmth, ethical grounding, patient-first values, and long-term fit consistently and equitably.
• Perform AI-assisted sourcing, screening, scheduling, and leverage assessment tools with accountability for data integrity, candidate equity, process transparency, and human oversight in consequential hiring decisions.
• Utilize applicant tracking systems, assessment tools, reporting platforms, and recruiting technologies to support efficient workflows, while tracking and analyzing recruiting metrics, market insights, and hiring outcomes to drive continuous improvement.
• Educate hiring managers on staffing best practices, structured, behavioral interviewing, candidate assessment, and equitable hiring practices.
• Navigate ambiguity, rapid organizational change, and shifting priorities with resilience, professionalism, and accountability, modeling change agility and a high standard of excellence for hiring partners and team members.
• Collaborate with People Operations and business leaders to support seamless hiring and onboarding, identify internal talent for new or evolving roles, contribute to employer branding and hiring manager capability building, and support broader Talent Acquisition and People Team initiatives as needed.
• Promote Guidehealth’s mission, values, and culture to candidates and external partners, and contribute to reducing regrettable early turnover through strong assessment, onboarding alignment, and hiring quality.

Talent Acquisition Specialist, Talent Integration

• Build meaningful relationships with patients and families, understanding their goals, barriers, and motivators.
• Create personalized care plans that go beyond diagnoses, addressing social determinants and emotional well-being.
• Coordinate care across providers and settings, ensuring safety, quality, and continuity.
• Educate and empower members to make informed decisions and navigate the healthcare system confidently.
• Collaborate with an interdisciplinary team, sharing insights and advocating for whole-person health.
• Use data as a tool for insight—not the driver of care—to identify opportunities and measure impact while keeping the patient at the center.
• Maintain compliance with regulatory standards while prioritizing compassion and connection.

RN Case Manager – Behavioral Health

Talent Acquisition Specialist, Integration

• Pulling, sorting, and analyzing data to determine member eligibility for the Population Health management Program.
• Coordinating and providing care that is timely, effective, equitable, safe, and member-centric while following HMO processes.
• Managing case assignments which includes outreach, documentation, monitoring for case progression, and case closure.
• Meeting reporting and documentation standards while engaging in collaborative meetings with department staff and clients.
• Assisting members in reaching wellness and health-autonomy by addressing barriers, social determinants, member motivators, and psychosocial issues.
• Helping members make informed decisions by educating them on navigation through the HMO and healthcare spectrum while promoting quality and cost-effective interventions and outcomes.
• Supporting operational aspects of the division to meet the organization’s customer requirements and satisfaction.
• Maintaining confidentiality related to all computer programs, medical records, and data.
• Participation in QM/UM Committee Meetings including material preparation, minutes, data collection, and analysis, reporting, and follow-up tasks which may require in-person attendance.
• Rotation in off-hour/weekend calls if applicable.
• Responsible for continued professional growth and education that reflects knowledge and understanding of current nursing care practice as outlined in the Illinois Practice Act.
• Other responsibilities as assigned and per any changes in annual program requirements.