Manage technology components by setting vision, direction, and execution for new technology delivery and optimization. Lead projects from design to implementation while supervising direct reports and fostering relationships between IT and business customers.
CareSource
53 Remote Job Openings at CareSource
Analyze, design, code, and test software throughout the production lifecycle to meet business requirements. This includes performing performance tests, conducting peer code reviews, and managing incident requests within an iterative methodology.
Define and champion the technology architecture strategy to align IT objectives with business goals. Lead the design of scalable, secure enterprise-wide solutions and mentor technical leaders to foster a culture of excellence.
Operations Data Visualization and Analytics Engineer IV
CareSource
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Full Time
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11 hours ago
CareSource
Develop scalable database and ETL solutions to automate data refreshes and deliver actionable insights via Power BI dashboards. Lead complex data transformation projects and mentor junior team members while establishing coding standards.
The BCBA serves as the clinical lead in developing evidence-based policies and practices for members with Autism. Responsibilities include overseeing ABA utilization management, conducting peer-to-peer discussions, and ensuring regulatory compliance.
The Data Scientist II designs and validates predictive, machine learning, and AI models to improve business processes across operational, clinical, and financial domains. Key duties include mining large datasets, developing algorithms, and communicating results to stakeholders for operationalization.
Define the technical architecture and engineering strategy for the ServiceNow platform across the enterprise. Lead the design and delivery of complex AI-driven automation and integration solutions while mentoring senior engineers.
Manage day-to-day and long-term information security risks to ensure compliance with risk management policies and tolerance levels. Monitor vendor risks and collaborate with stakeholders to develop and execute risk mitigation plans.
Clinical Care Reviewer II (Remote)(Must Have - Unrestricted Massachusetts RN License)
CareSource
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Full Time
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17 hours ago
CareSource
Responsible for processing medical necessity reviews for healthcare authorizations and coordinating care transitions for members. The role involves monitoring healthcare delivery and collaborating with medical directors and care partners.
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 and external providers to ensure continuity of care and schedule initial nurse intake visits.
The AVP of Actuarial Science drives company strategy and manages actuarial functions including pricing, forecasting, and performance monitoring to improve profitability. They oversee the alignment of actuarial inputs with financial reporting and represent the organization in communications with regulators and executive leadership.
Senior Manager, Strategic Sourcing & Vendor Performance
CareSource
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Full Time
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4 days ago
CareSource
Lead a team in managing the full vendor lifecycle, from strategic sourcing and selection to performance monitoring and category management. Establish KPIs and reporting mechanisms to ensure vendor agreements maximize results and comply with regulatory requirements.
The Healthcare Analyst III identifies and quantifies opportunities to reduce medical costs through the analysis of healthcare utilization patterns. They present analytical findings to management and mentor developing analysts to improve network provider performance.
Manage daily accounting and reporting operations, including the preparation of internal and external financial statements. Lead audit functions and ensure compliance with GAAP, STAT, and NAIC statutory requirements.
Lead and direct the day-to-day activities of investigative staff to reduce turnaround time and improve outcomes in program integrity. Coordinate training, mentor direct reports, and collaborate cross-functionally to mitigate fraud, waste, and abuse.
The specialist handles routine service inquiries from members and providers regarding claims, benefits, and eligibility. They are responsible for maintaining accurate documentation and ensuring compliance with HIPAA and federal regulations.
The Behavioral Health Medical Director ensures the overall safety of patients with behavioral health diagnoses, focusing specifically on safe prescribing and evidence-based clinical policies. They lead quality improvement initiatives, manage utilization reviews, and serve as the primary clinical liaison to members, providers, and state agencies.
The Clinical Psychologist provides behavioral health coverage determinations for utilization management to ensure medically necessary and cost-effective care. They serve as a clinical lead in developing evidence-based policies, managing quality improvement initiatives, and acting as a liaison to members and state agencies.
The Scrum Master II guides and coaches the Scrum Team and organization on Agile/Scrum practices and values using a servant leadership style. They are responsible for removing impediments, facilitating collaboration, and supporting the Product Owner in managing the product backlog.
Senior Director, Clinical Data Governance and Integration
CareSource
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Full Time
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7 days ago
CareSource
Leads the development and execution of enterprise clinical data governance and integration strategies to support growth objectives. Oversees data inventories, acquisition opportunities, and cross-functional alignment between IT and business domains.
Provides analytical support and leadership for claims projects, including monitoring IT tickets and developing policies and procedures. Researches and resolves provider claim issues by analyzing system configurations and payment data.
Lead actuarial processes including pricing, forecasting, and reserving to support company goals and strategic recommendations. Manage the development of actuarial models and oversee IBNR reserve estimates for various lines of business.
Lead the Voice of the Customer and Customer Experience programs to drive innovation and efficiency within the call center. Define the AI roadmap and translate speech analytics into actionable insights to improve member and provider experiences.
PI Medical Coding Reviewer II (CPC, RHIT or RHIA required)
CareSource
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Full Time
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7 days ago
CareSource
Responsible for reviewing medical records and claims to make payment decisions and identify potential fraud, waste, or abuse. Collaborates with internal departments to resolve claim disputes and implements process improvements to enhance audit efficiency.
Drive company strategy and manage actuarial expertise regarding rate levels and negotiations with State Medicaid Departments to ensure soundness and profitability. Oversee rate filing, bid development, and financial reporting processes while providing strategic insights to C-suite leadership.
The Market Behavioral Health Medical Director ensures the safety of patients with behavioral health diagnoses, focusing specifically on safe prescribing practices. They lead clinical policy development, oversee utilization management, and serve as the primary psychiatric liaison to state agencies and providers.
Manager, Information Technology – Encounters IT (Transformation & Architecture Focus)
CareSource
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Full Time
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18 days ago
CareSource
Lead the modernization and technology strategy for the Encounter Management ecosystem, focusing on cloud adoption and scalable architecture. Manage cross-functional engineering teams to deliver compliant, high-performance encounter processing platforms.
Perform medical necessity reviews of complex clinical appeals to ensure timely, accurate, and compliant determinations. Collaborate with cross-functional teams and stakeholders to standardize appeals processes and improve clinical outcomes.
Develop and execute staffing strategies to optimize digital and human resources while ensuring regulatory compliance and cost-efficiency. Oversee external regulatory reporting and lead data-driven continuous improvement initiatives using Speech Analytics and Lean methodologies.
Quality Risk Adjustment Advisor IV (Health Plan experience required)
CareSource
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Full Time
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19 days ago
CareSource
Lead Quality Risk Adjustment (QRA) programs, focusing on prospective programs, chart retrieval, and coding processes. Partner with vendors and internal teams to integrate AI technologies to improve data accuracy and operational efficiency.
Lead and direct a customer care team to meet regulatory, compliance, and department standards. Responsibilities include conducting coaching sessions, analyzing performance data, and fostering a collaborative team environment.
Develop and optimize provider reimbursement strategies using advanced data analysis, financial modeling, and AI tools. Evaluate payment methodologies and conduct contract repricing to provide actionable insights for contracting decisions.
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.
Care Manager Mom and Baby RN - Must Reside in Indiana
CareSource
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Full Time
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25 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.
Director, Pharmacy Clinical Strategy(Preferred Experience in Medical Drug Management Strategy)
CareSource
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Full Time
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a month 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.
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.
VP, Network Strategy & Contracting(Preferred Managed Care Experience And Must Live In Nevada)
CareSource
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Full Time
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a month 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.
Remote Operations Specialist - Must reside in New York
CareSource
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Full Time
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a month 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.
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.
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.
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.
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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2 months 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.
Mom and Baby Care Manager - RN - Must reside in Nevada
CareSource
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Full Time
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4 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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6 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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6 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.
