Leads the implementation and maintenance of financial system solutions, focusing on master data management, security, and reporting. Responsible for the full delivery life cycle, including requirements analysis, design, testing, and end-user training.
CareSource
42 Remote Job Openings at CareSource
The specialist manages provider contracting, recruitment, and engagement for strategic health partners to improve network performance. They are responsible for negotiating reimbursement rates, driving quality outcomes through Value Based Reimbursement, and providing practice transformation support.
PI Medical Coding Reviewer III (CPC, RHIT or RHIA required)
CareSource
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Full Time
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9 hours ago
CareSource
The role involves conducting complex medical record audits and managing disputes to ensure program integrity in pre-pay and post-paid processes. It also requires mentoring audit analysts, identifying system gaps, and serving as a primary resource for provider escalations.
The Onboarding Specialist serves as the primary contact for new members transitioning to health plans, coordinating healthcare services and educating them on plan offerings. They liaise between internal providers and external healthcare entities to ensure seamless care transitions and establish initial care teams.
Manage and negotiate assigned contracts while conducting financial impact analyses to inform decision-making. Lead a team of direct reports and cross-functional workgroups to ensure network adequacy and timely implementation of provider contracts.
Oversees the daily performance of grievance and appeals specialists to ensure compliance with Medicaid, Medicare, and HIPAA guidelines. Responsible for staff supervision, regulatory reporting, and identifying process improvements to resolve member and provider issues.
The specialist resolves routine service inquiries from members and providers regarding claims, benefits, and eligibility. They are responsible for maintaining accurate documentation and ensuring adherence to HIPAA and federal regulations.
Manage digital products from planning through execution, focusing on growth, optimization, and customer experience. Coordinate with cross-functional teams and external agencies to maintain backlogs and align digital initiatives with business goals.
Care Manager Mom and Baby RN - Must Reside in Indiana
CareSource
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Full Time
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5 days ago
CareSource
Collaborate with inter-disciplinary teams to develop and implement person-centered care plans for members. Coordinate healthcare resources and community supports to improve health outcomes and address social determinants of health.
Leads the creation of formulary design best practices and market-competitive management strategies across multiple lines of business. Manages the Value Assessment Committee and oversees the operational execution of the formulary management team.
Director, Pharmacy Clinical Strategy(Preferred Experience in Medical Drug Management Strategy)
CareSource
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Full Time
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5 days ago
CareSource
Leads the strategic development of formulary and medical drug management strategies across all business lines. Oversees clinical policy development, P&T committees, and the operational management of pharmacy benefit configurations.
Director, Market Strategic Initiatives and Vendor Performance
CareSource
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Full Time
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6 days ago
CareSource
Oversees the delivery of critical services including DME vendor management, home modifications, and wheelchair repair to improve member experience. Leads strategic initiatives to ensure regulatory compliance and operational excellence for safe community living.
Lead statewide membership growth and enrollment targets for Medicare and DSNP product lines in Ohio. Oversee field sales, broker channels, and business development while building strategic partnerships with providers and community organizations.
Oversees business analysis initiatives to drive operational excellence and leads cross-functional process improvements aligned with organizational strategy. Acts as a primary liaison between stakeholders and technical teams to manage the claim lifecycle and implement operational readiness frameworks.
Director, Cybersecurity Defense(Preferred Experience in Managed Care/Healthcare)
CareSource
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Full Time
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7 days ago
CareSource
Directs the implementation and maintenance of information security controls and technologies to protect business interests. Manages security threats, vulnerabilities, and compliance programs while leading and coaching a team of security professionals.
VP, Network Strategy & Contracting(Preferred Managed Care Experience And Must Live In Nevada)
CareSource
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Full Time
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7 days ago
CareSource
Lead the creation and execution of the Market Network strategic plan, focusing on Value Based Purchasing and provider contracting. Manage relationships with stakeholders, regulatory entities, and healthcare providers to ensure network access and compliance.
The Actuarial Analyst I provides data analysis and actionable recommendations to support corporate initiatives and improve efficiency. Key duties include calculating IBNR reserves, performing profitability reports, and evaluating government reimbursement risks.
Remote Operations Specialist - Must reside in New York
CareSource
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Full Time
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8 days ago
CareSource
Provides clerical and administrative support for Care Management and Member Services, including ordering member services and processing authorizations. Handles inbound and outbound calls to assist members and coordinate with the clinical team.
PI Medical Coding Reviewer I (CPC, RHIT or RHIA required)
CareSource
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Full Time
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9 days ago
CareSource
Responsible for managing medical record requests, tracking, and performing pre-payment and post-payment claim reviews. The role involves making payment decisions based on medical coding guidelines and identifying potential fraud, waste, or abuse.
Collaborates with leadership to evaluate and implement HEDIS data and process improvements using quality improvement methodologies. Leads work teams to diagnose gaps, develop reusable solutions, and monitor vendor and community partner performance.
SIU Investigator Lead (Must live in OH or surrounding states)
CareSource
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Full Time
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13 days ago
CareSource
Lead the Special Investigations Unit in identifying and mitigating fraud, waste, and abuse while managing communications with federal and state regulatory agencies. Oversee complex investigations, mentor the team, and utilize data analytics to detect billing anomalies and emerging FWA trends.
Develops and implements corporate clinical care standards and quality improvement plans to ensure compliance with national standards. Provides operational leadership, medical reviews, and clinical consultation to support members and providers.
Leads the strategy, execution, and submission of DSNP bids while ensuring compliance with CMS guidance and regulatory requirements. Collaborates with cross-functional teams to manage benefit design, risk assessments, and competitive positioning.
Prevention Health Specialist - Must be Mississippi Based
CareSource
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Full Time
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21 days ago
CareSource
The specialist educates members and providers on preventive health services to ensure compliance with state and federal guidelines. They are responsible for executing quality programs, monitoring gaps in care, and reporting on outreach activities.
Provides end-to-end operational leadership for DSNP products to ensure regulatory compliance, scalability, and readiness across markets. Translates DSNP strategy into executable processes through cross-functional partnership and performance oversight.
Responsible for provider contracting, recruitment, and acting as the engagement lead for strategic health partners to drive network performance. The role involves negotiating contracts, analyzing financial data, and supporting practice transformation through the PCMH model.
The Medical Director provides clinical consultation, prior authorization reviews, and training for staff and providers. They are also responsible for quality improvement initiatives, policy development, and ensuring regulatory compliance for member safety.
The analyst ensures compliance with State and Federal Network Adequacy Standards by reviewing market operation processes and systems. They manage network initiatives, conduct data analysis on provider standards, and interface with regulatory agencies as a subject matter expert.
Design and develop technologies to monitor IT systems for suspicious activity and intrusions. Administer security policies, manage vulnerability remediation, and ensure compliance with regulatory requirements like HIPAA.
instED Virtual Medical Control (VMC) Nurse Practitioner - POOL((Part Time - $91.67 per hour/Remote/Pacific or Mountain Time)
CareSource
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Full Time
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a month ago
CareSource
The VMC Nurse Practitioner provides medical decision-making, diagnostics, and treatment for patients seen by Mobile Integrated Healthcare services. They serve as the clinician of record, prescribing short-term treatments and documenting encounters via telehealth technologies.
Responsible for the architectural strategy and operationalization of clinical system configurations within the Health Edge/Guiding Care suite. This includes defining technology standards, creating roadmaps, and collaborating with business leaders to align technical solutions with organizational goals.
Market Chief Medical Director(Must Live In Michigan)
CareSource
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Full Time
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2 months ago
CareSource
The Market Medical Director implements clinical care standards and ensures compliance with quality guidelines while providing leadership to market provider networks. They also participate in utilization management, peer-to-peer discussions, and quality initiatives to support market goals and regulatory requirements.
The Triage Nurse will utilize evidence-based guidelines to assess and direct members to the appropriate level of care for physical and behavioral health needs. They will also act as a patient advocate, providing education and facilitating access to healthcare resources while maintaining accurate documentation.
The specialist coordinates comprehensive housing support strategies and care management for Nevada Medicaid members to ensure stable tenancy. They also facilitate access to community resources, manage housing applications, and provide ongoing education on tenant rights and responsibilities.
Mom and Baby Care Manager - RN - Must reside in Nevada
CareSource
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Full Time
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3 months ago
CareSource
The Care Manager collaborates with an inter-disciplinary care team, providers, and community organizations to improve quality of life for members through culturally competent care delivery. This involves facilitating communication, coordinating services, conducting strength-based assessments, and developing/evaluating person-centered care plans to address behavioral, physical, and social determinants of health needs.
The Managing Actuary will provide leadership and direction to achieve team goals, overseeing key actuarial processes such as pricing, forecasting, and reserving for assigned lines of business. This role involves developing and communicating strategic recommendations to leadership and managing the development and maintenance of actuarial models.
The AI Developer will design and implement AI models and algorithms tailored to diverse business challenges while defining and leading the architecture of Generative AI platforms, including LLMs, vector databases, and inference pipelines. Essential functions also involve rapidly prototyping solutions, leveraging AI-assisted development tools, and collaborating with various teams to integrate AI capabilities into production-ready systems.
The Medical Director supports staff by providing training, clinical consultation, and clinical case review for members, while also conducting prior authorization medical reviews and participating in peer-to-peer discussions. Essential functions include provider education, clinical appeals review, fraud/abuse investigations, and contributing to policy and quality improvement initiatives.
Medical Director (REMOTE Appeals Medical Director - Pacific Standard Time, Managed Care Experience, Family Medicine and Appeals Experience Preferred")
CareSource
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4 months ago
CareSource
The Medical Director supports staff by providing training, clinical consultation, and clinical case review for members, which includes conducting prior authorization medical reviews and participating in peer-to-peer discussions. Essential functions also involve conducting clinical reviews for appeals cases, participating in fraud/abuse investigations, and contributing to policy and quality improvement initiatives.
The Care Navigator conducts telephonic outreach to members and providers to confirm service details, coordinate scheduling, and ensure accurate documentation of care coordination activities. This role also involves serving as a support resource for requests and escalations, and collaborating with the care team to ensure smooth communication and continuity of care.
Medicare Sales Representative - Base Salary + Commission Opportunities (Must Reside in Ohio)
CareSource
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Full Time
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5 months ago
CareSource
The Medicare Sales Representative will empower the community by developing educational opportunities and engaging with seniors about Medicare options. They will also build relationships with stakeholders to drive enrollment and sales success.
instED Virtual Medical Control Physician (Per Diem/Remote/Pacific or Mountain Time)
CareSource
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Full Time
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5 months ago
CareSource
The Virtual Medical Control Physician provides medical decision making for patients seen by instED's Mobile Integrated Healthcare service. They serve as the clinician of record, prescribe treatments, document encounters, and communicate follow-up needs to the care team.
