The Clinical Training Specialist facilitates clinical, operational, and professional-skills training for internal and external audiences. They are responsible for developing training materials using the ADDIE model and evaluating training effectiveness through performance data and stakeholder feedback.
The manager will serve as a subject matter expert for Community HealthChoices, ensuring departmental integrity and compliance with state and federal requirements. They will oversee transitional services, manage departmental data, and coordinate outreach and training initiatives.
Develops complex analyses and predictive models to solve operational problems and quantify competitive performance. Defines business problems, applies advanced mathematical concepts, and creates reports to measure organizational performance.
The Prior Authorization Tech I interprets clinical criteria to process and approve pharmacy and medical authorization requests. They also handle inbound and outbound calls, assist with appeals, and coordinate with pharmacists and clinical programs.
The Prior Authorization Tech I interprets clinical criteria to approve or process pharmacy authorization requests while maintaining productivity and quality standards. They also handle inbound and outbound calls to gather necessary information and assist with appeals processing.
The Technical Project Manager Senior leads complex healthcare technology projects by bridging the gap between business stakeholders, engineering teams, and data operations. They drive project execution using Agile methodologies and Azure DevOps while ensuring alignment with strategic healthcare initiatives and regulatory standards.
The Corporate Director of Accreditation and Compliance provides strategic leadership for accreditation readiness, regulatory compliance, and quality governance across the organization. This role oversees NCQA accreditation, manages audit readiness, and drives continuous improvement through cross-functional partnerships and risk mitigation.
The HEDIS Analyst manages the full lifecycle of HEDIS measures, ensuring data accuracy and interpreting results into actionable recommendations. They collaborate with internal departments and external vendors to support quality initiatives and prepare for audits.
The Technical Analytics Product Manager will drive the development and enhancement of the analytics product portfolio by collaborating with cross-functional teams. They are responsible for defining product requirements, conducting user acceptance testing, and monitoring performance metrics to inform future enhancements.
The Senior Manager IT leads the enterprise Master Data Management and Reference Data Management strategy, architecture, and delivery across member and provider domains. They are responsible for managing cloud migrations, optimizing data platforms, and ensuring compliance with healthcare industry regulations.
The Actuarial Analyst will calculate and monitor medical cost trends, benefit changes, and provider reimbursement impacts. They will also assist in maintaining medical economic databases and preparing internal and external reporting communications.
The Senior Clinical Quality Performance Specialist oversees and implements quality initiatives, utilizing data analytics to drive clinical and service improvements. They manage accreditation activities, HEDIS and CAHPS reporting, and collaborate with stakeholders to identify and resolve process barriers.
The Market President provides strategic vision and operational leadership for the Ohio health plan, focusing on growth, quality improvement, and member retention. They are responsible for full profit and loss management, building key stakeholder relationships, and ensuring compliance with regulatory standards.
Manage and coordinate care for members with behavioral health conditions by developing individualized care plans and facilitating transitions of care. Conduct face-to-face visits and collaborate with multidisciplinary teams to ensure optimal health outcomes and compliance with treatment plans.
The Pharmacy Technician I provides front-line customer support by handling inbound inquiries from members, pharmacies, and prescribers. They are responsible for entering customer data, educating prescribers on formulary processes, and ensuring contact handling accuracy.
The specialist manages the full life cycle of member and provider appeals and grievance cases, including intake, investigation, and documentation. They serve as a liaison between internal departments and stakeholders to ensure compliance with federal, state, and accreditation standards.
The Senior Provider Network Operations Analyst manages operational accuracy, regulatory compliance, and claims configuration within the provider network. They are responsible for auditing payment integrity, resolving escalated provider issues, and serving as a subject matter expert for state-specific reimbursement rules.
The Principal Architect will lead the technical and solution architecture for the organization's transformation from PeopleSoft to Workday. They will also provide cross-functional leadership to modernize enterprise applications and establish long-term architectural strategies.
The clinical reviewer is responsible for evaluating requests for long-term services and supports using evidence-based guidelines and clinical judgment. They coordinate with service providers to ensure appropriate care authorization and maintain compliance with organizational policies and state regulations.
The Care Connector conducts comprehensive health risk assessments and develops individualized care plans to support member health goals. They also monitor member progress, provide health education, and coordinate access to community resources and healthcare services.
The Care Manager provides remote care coordination for HIDE D-SNP members by conducting comprehensive assessments and developing individualized care plans. They collaborate with interdisciplinary teams to address medical, behavioral, and social needs while ensuring compliance with regulatory requirements.
The Medical Director performs daily medical reviews, appeals, and peer review activities while implementing evidence-based practice guidelines. They also oversee clinical care quality and collaborate with multidisciplinary teams to ensure compliance with contractual and regulatory obligations.
The Maternal Care Manager assesses, plans, and coordinates care for members to achieve optimal health outcomes through personalized care plans. They act as a single point of contact and advocate, facilitating services across physical, behavioral, and social health domains.
The Utilization Management Technician coordinates, generates, and tracks correspondence, faxes, and authorizations for service review functions. They interact with facilities, providers, and vendors to facilitate the receipt of information for prompt review and response.
The Member Services Specialist serves as the primary point of contact for youth, families, and providers, managing inquiries and registration processes. They are responsible for resolving calls, maintaining accurate documentation, and addressing member complaints according to established procedures.
The Director will serve as a subject matter expert for Long-Term Services and Support (LTSS) and act as the primary contact for the South Carolina Department of Health and Human Services. They are responsible for overseeing care teams, maintaining operational policies, and ensuring quality performance metrics are met in accordance with state contracts.
The Director of Business Development is responsible for driving strategic growth initiatives and expanding market opportunities for Medicaid and other company products. This role involves leading cross-functional teams, managing stakeholder relationships, and overseeing the development of competitive proposal responses.
The LTSS UM Technician coordinates and tracks correspondence, authorizations, and faxes while interacting with providers and staff to facilitate review processes. They also perform data entry for authorizations and maintain operational reports to ensure compliance with utilization management requirements.
The Care Manager assesses, plans, and coordinates comprehensive care for members to achieve optimal health outcomes. They act as a single point of contact and advocate, facilitating services across physical, behavioral, and social domains.
The Network Contractor is responsible for negotiating provider contracts to ensure an adequate, compliant, and marketable network. They also support network development strategy and manage provider satisfaction through education and communication.
The Data Engineering Architect designs, develops, and tests ETL and BI solutions while managing supplemental clinical data for quality measurement. They also partner with stakeholders to align data governance agendas and lead data acquisition efforts across the organization.
The Senior Account Executive is responsible for developing and maintaining strong relationships with providers to drive performance in risk-based and value-based care arrangements. They also oversee network development, resolve provider disputes, and implement educational programs to support network management strategies.
The Behavioral Health Caseworker manages and coordinates care for members with behavioral health conditions, serving as the primary point of contact for the care team. They develop and monitor individualized care plans, facilitate transitions of care, and conduct face-to-face assessments in various community and clinical settings.
The Manager of IT, Enterprise Data Governance & Quality, will lead the development and operationalization of enterprise-wide data governance and quality frameworks. This role involves defining strategic roadmaps, ensuring data protection, and collaborating with business and technology teams to drive continuous quality improvements.
The Care Connector supports integrated care management program interventions by processing calls from members and providers. They identify members with care gaps and assist them in accessing plan benefits and community resources under the direction of clinical staff.
The Medical Director leads the Utilization Management program, ensuring clinical appropriateness of care and adherence to medical policies. They collaborate with multidisciplinary teams to analyze utilization trends, conduct peer-to-peer reviews, and implement interventions to improve clinical effectiveness.
The Director of ICT Care Coordination leads the strategic direction and operational execution of population health and care coordination programs. They oversee clinical staff, ensure regulatory compliance, and drive performance improvement initiatives to enhance member health outcomes.
