The Compliance Manager oversees pharmacy and PBM delegation compliance, ensuring effective program governance through monitoring, reporting, and actionable insights. They partner with stakeholders to remediate issues, manage investigations, and maintain audit readiness across multiple lines of business.
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 Behavioral Health Utilization Management Reviewer conducts medical necessity reviews for inpatient and outpatient services using clinical knowledge. They ensure appropriate service authorization, identify care coordination opportunities, and maintain compliance with relevant laws and policies.
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 technician interprets clinical criteria to process prior authorization requests and utilizes member claims history to approve or refer requests. They also handle inbound and outbound calls regarding authorizations and assist with appeals processing.
The Medical Director leads the Utilization Management program, ensuring patient care decisions and referrals are medically appropriate. They also collaborate with multidisciplinary teams to develop clinical policies and improve the effectiveness of medical management strategies.
The Service Coordinator will conduct face-to-face assessments to identify and manage the physical, behavioral, and social needs of Medicaid participants. They are responsible for leading the participant-centered planning process and ensuring access to necessary long-term services and supports.
Develop and deploy end-to-end machine learning pipelines on the Azure Databricks platform while collaborating with cross-functional teams. Ensure the scalability, reliability, and security of ML systems in production environments through effective monitoring and CI/CD processes.
The Product Manager drives the strategy, design, and delivery of clinical technology products to support utilization management, care management, and quality operations. They act as the bridge between clinical operations, data engineering, and technology to ensure scalable, data-enabled products that improve healthcare outcomes.
The Transition Care Manager assesses member needs to develop and implement individualized care plans while coordinating physical, behavioral, and social services. They serve as a primary advocate and point of contact, ensuring all care delivery complies with NCQA standards and regulatory requirements.
The Pharmacist is responsible for making medical necessity and benefit determinations on prior authorization requests based on clinical guidelines. They also provide clinical support to the Customer Care Center and assist with fraud and abuse program oversight.
The Dental Account Executive builds and maintains relationships between health plans and dental providers to ensure effective service delivery. They also coordinate issue resolution, manage provider data accuracy, and support quality management initiatives.
The Service Coordinator identifies and manages the long-term care needs of Medicaid participants through face-to-face assessments and ongoing coordination. They lead the participant-centered planning process and ensure compliance with Community Health Choices requirements.
The Care Manager facilitates access to behavioral health and therapeutic services for youth by creating integrated service plans. They are responsible for making timely intensity of service determinations and managing crisis or emergency calls.
The Business Systems Analyst analyzes FACETS configuration change requests to determine technical scope and system impact. They serve as a technical consultant for health plan initiatives and manage multiple configuration projects simultaneously.
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 Care Manager assesses, plans, and coordinates care for members to help them achieve optimal health through self-management. They act as a single point of contact and advocate, ensuring high-quality care delivery in compliance with NCQA and regulatory standards.
The specialist coordinates and monitors utilization management program objectives while supporting performance improvement projects and clinical activities. They are responsible for developing and maintaining policies, procedures, and program documents to ensure compliance with regulatory and accrediting standards.
The Account Executive develops and maintains strong relationships with healthcare providers to drive performance and ensure provider satisfaction. They are responsible for provider education, contract support, and resolving disputes while managing network adequacy across assigned regions.
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 LTSS Reviewer is responsible for evaluating requests for inpatient and outpatient services to ensure appropriate care and service coordination. They apply medical guidelines to authorize services and document all utilization determinations within enterprise systems.
The Service Coordinator will identify, evaluate, and manage the needs of Medicaid participants by performing face-to-face assessments and telephonic follow-ups. They will lead the participant-centered planning process to ensure access to necessary physical, behavioral, and social services.
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 Service Coordinator will identify and manage the needs of Medicaid participants by conducting face-to-face assessments and coordinating long-term services and support. They are responsible for leading the participant-centered planning process and ensuring compliance with Community Health Choices requirements.
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 Manager Social Care oversees the implementation of social care strategies and manages day-to-day operations of Social Care Partners. This role involves building strategic community partnerships and collaborating with internal and external stakeholders to improve member outcomes.
The Instructional Designer develops and updates training materials and experiences to ensure effective knowledge acquisition for associates. This role collaborates with cross-functional teams to deliver live and virtual training, primarily focused on systems and service coordination.
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.
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 Manager of Business Systems oversees the operational health and governance of collaboration platforms like SharePoint and Microsoft 365 to support enterprise growth and proposal development. This role also provides direct supervision to staff, manages consultant lifecycles, and translates complex business needs into scalable technology solutions.
The Senior Salesforce Developer will design, develop, and implement complex system integrations and Salesforce features to support Member CRM solutions. They are responsible for analyzing technical requirements, ensuring adherence to enterprise architecture standards, and collaborating with the team to deliver high-quality healthcare IT solutions.
The Senior Medical Director oversees clinical care quality, utilization management, and behavioral health programs while ensuring adherence to regulatory and contractual requirements. They lead a team of medical directors, manage medical policy development, and drive continuous quality improvement initiatives.
Manage and support the Salesforce development and delivery team while overseeing the technical aspects of Member CRM projects. Lead and mentor developers to ensure successful implementation of complex system integrations and Salesforce features.
The role involves overseeing provider data, reimbursement rules, and operational workflows to ensure contractual compliance across various health products. The individual will serve as a subject matter expert, managing provider escalations and collaborating with internal departments to optimize claims processing and network reporting.
The manager will oversee departmental integrity, data management, and compliance with Community HealthChoices Long-Term Service and Support requirements. They are responsible for developing workflows, training staff, and managing transitional services while maintaining key performance metrics.
The manager will oversee departmental integrity, data management, and compliance with Community HealthChoices Long-Term Service and Support requirements. They are responsible for developing workflows, conducting audits, and coordinating outreach and training for staff and stakeholders.
Lead and coordinate clinical quality reviews of member concerns and medical records using standards of care. Support accreditation, HEDIS activities, and Quality Assessment and Performance Improvement (QAPI) committee processes.
Lead the development and execution of the enterprise strategic plan and annual business plan to advise the CEO and Executive Council. Manage strategic growth initiatives, evaluate M&A opportunities, and lead a team in executing key corporate projects.
Lead the launch, growth, and overall operational performance of the Indiana health plan. Serve as the primary market-facing leader to build relationships with state agencies, providers, and community partners.
Develop large reporting layers, executive decks, and metrics to support the Total Cost of Care revenue and expense review process. Collaborate with operational partners to identify high-value opportunities for savings and revenue growth.
Draft and refine narrative sections for state Medicaid managed care bids, translating technical information into compliant and compelling prose. Collaborate with subject matter experts and utilize AI-enabled tools to produce high-quality, evaluable proposal responses.
Lead a team of technical leads and architects to oversee critical enterprise integration and API platforms. Drive the modernization of platforms using cloud-native practices, API-first strategies, and AI-driven automation.
Lead the development of complex, scenario-based narratives and high-visibility sections for state Medicaid managed care bids. Collaborate with subject matter experts and leadership to translate technical operational details into compelling, compliant, and evaluable prose.
Develop and maintain strong relationships with healthcare providers to drive performance and satisfaction. Support network management strategies, resolve provider disputes, and conduct educational orientation sessions.
