The Clinical Care Reviewer II is responsible for conducting medical necessity reviews for behavioral health services and coordinating care for members. They also assist with discharge planning and engage with collaborative care partners to facilitate appropriate transitions in care.
The Customer Care Resolution Specialist acts as a subject matter expert to resolve escalated inquiries from members and providers while coaching new hires. They are responsible for identifying process gaps, maintaining service levels, and ensuring compliance with HIPAA and state regulations.
The Care Manager Plus coordinates comprehensive care for members by facilitating inter-disciplinary team meetings and developing individualized, person-centered care plans. They serve as a central point of contact to manage health needs, address barriers to care, and ensure effective utilization of community and healthcare resources.
The Community Based Care Coordinator manages and coordinates care for dual-eligible beneficiaries by integrating health services and community resources. They conduct comprehensive assessments, develop individualized care plans, and collaborate with interdisciplinary teams to improve health outcomes.
The Data Scientist I supports the design and validation of predictive and machine learning models to improve business processes. They are responsible for mining large datasets, developing algorithms, and communicating analytical insights to key stakeholders.
The Medical/Clinical Policy Writer researches and develops complex medical, behavioral health, and reimbursement policies while ensuring compliance with state and federal regulations. They collaborate with interdisciplinary teams and subject matter experts to support policy governance and implement deliverables across various product lines.
The EES Program Manager leads enterprise-level programs by ensuring alignment with strategic objectives and managing complex, cross-functional initiatives. This role oversees program execution, governance, stakeholder communication, and the adoption of AI tools to improve engineering productivity.
The analyst manages day-to-day information security risks and ensures compliance with organizational policies and risk tolerance. They are responsible for monitoring vendor risks, executing mitigation plans, and reporting findings to management.
The Employee Relations Partner III serves as a strategic advisor to business leaders, managing complex employee relations issues and driving organizational effectiveness. This role involves conducting investigations, facilitating change management, and utilizing data insights to foster a compliant and positive work environment.
The Customer Care Specialist resolves routine service inquiries regarding claims, benefits, and eligibility for members and providers. They are responsible for maintaining accurate documentation and ensuring compliance with all HIPAA and regulatory requirements.
The Director of Employee Relations establishes and leads the enterprise-wide employee relations strategy, governance framework, and standard practices to ensure consistent resolution of workplace matters. This role acts as a strategic advisor to executive leadership, managing high-risk investigations and driving organizational effectiveness through data-driven insights.
The Enterprise Medical Director develops and implements clinical care standards, quality initiatives, and utilization management strategies to ensure regulatory compliance. They also provide clinical leadership, conduct medical reviews, and collaborate with market leaders to define strategic goals.
The Director manages relationships with health partners to ensure contract specifications are met and drives initiatives to improve quality measures and cost utilization. They lead a cross-functional team to execute network strategies, manage budgets, and facilitate effective communication between the organization and its health partners.
The Applied AI Scientist IV leads the design, development, and operationalization of advanced AI solutions to improve healthcare operations and patient outcomes. This role provides enterprise-wide technical leadership, establishes AI standards, and mentors scientific teams to drive innovation.
The Project Manager I is responsible for the successful delivery of small complexity projects, including managing schedules, budgets, and project documentation. They lead stakeholders, coordinate resources across business and IT departments, and ensure compliance with EPMO governance standards.
The Architect II is responsible for defining and overseeing technology designs, roadmaps, and lifecycle management to support enterprise objectives. They will collaborate with IT leadership to establish architectural standards and provide guidance on strategic technical initiatives.
The SIU Investigator III investigates complex allegations of healthcare fraud, waste, and abuse by analyzing claims data and provider billing patterns. They also serve as a subject matter expert, coordinating audits and collaborating with legal and law enforcement partners to drive investigative outcomes.
The Team Lead supervises a team of RN Reviewers to ensure timely and high-quality submission of assessments while maintaining compliance with Mass Health standards. They are responsible for hiring, training, monitoring team productivity, and collaborating with management to optimize assessment workflows.
The Encounters Systems Analyst II is responsible for analyzing encounter data to ensure compliance with Service Level Agreements and regulatory requirements. They will collaborate with internal departments and external stakeholders to improve data accuracy, streamline processes, and support critical reporting initiatives.
The Medical Director provides clinical expertise through case reviews, medical claims audits, and provider education to ensure quality care and regulatory compliance. They collaborate with cross-functional teams to develop clinical standards, investigate fraud, and support organizational quality improvement initiatives.
Lead the development and deployment of advanced analytical models, dashboards, and automated solutions to detect fraud, waste, abuse, anomalies, and payment integrity risks across healthcare claims. Guide investigations and enterprise initiatives, evaluate outcomes, support legal proceedings, present recommendations to stakeholders, and mentor analysts and data scientists.
The developer will design, configure, and deploy AI-enabled applications and user interfaces to support business workflows. They will collaborate with data scientists and engineers to integrate AI model outputs into production environments using both low-code tools and custom code.
Lead the design, development, and operationalization of advanced AI and machine learning solutions to improve healthcare operations and patient outcomes. Establish technical standards, mentor data scientists, and collaborate with cross-functional stakeholders to drive enterprise AI strategy.
The LTSS Provider Relations Account Manager manages relationships with LTSS and HCBS providers to ensure operational efficiency, provider satisfaction, and improved member access to care. This role involves conducting onboarding, providing education on billing and regulations, and collaborating with internal stakeholders to resolve provider issues.
The Payment Cycle Analyst II provides analytical support for claims-related projects, including defining clinical and payment policy requirements and conducting root cause analysis for reimbursement errors. They also document payment policies, collaborate with health partner teams, and ensure accurate configuration of clinical editing systems.
The Director of Enrollment Operations provides strategic leadership for enterprise enrollment across product lines, ensuring regulatory compliance and data integrity. This role manages end-to-end enrollment lifecycles, vendor relationships, and system integrations while driving process optimization and automation initiatives.
The HR Business Partner III acts as a strategic advisor to senior leadership, aligning HR initiatives with business goals and organizational culture. They are responsible for managing employee relations, organizational design, and collaborating with HR Centers of Excellence to drive performance and engagement.
The associate serves as an operational advocate for brokers and agencies, managing complex pre and post-enrollment issues and inquiries. They are responsible for resolving member-related escalations, processing requests, and educating prospective members on health plan benefits.
The Manager, Enrollment Operations provides leadership to the enrollment team to ensure operational efficiency, quality outputs, and compliance with regulatory requirements. They are responsible for managing staff, overseeing financial and member reconciliation, and implementing process improvements for enrollment technology.
The Medical Director provides clinical oversight, conducts case reviews, and supports staff through training and education. They also participate in quality improvement initiatives, policy development, and regulatory compliance activities.
The Senior Director, Market Chief Financial Officer provides financial leadership and strategic oversight to regional markets, ensuring accurate financial reporting and target achievement. They are responsible for managing departmental staff, coordinating regulatory filings, and driving quality and revenue maximization initiatives.
The VP of Legal & Regulatory Affairs leads the legal and compliance functions for ElderServe Health, serving as a trusted advisor to executive leadership. They are responsible for developing regulatory strategies, mitigating business risks, and ensuring alignment with CareSource's operational objectives.
The Team Lead provides front-line management and support for community-based care management operations, including staff supervision and training. They also serve as an interdepartmental liaison to monitor service levels and coordinate with community partners to maximize resource utilization.
The Community Marketing Representative II supports enrollment and retention strategies by conducting community outreach and educational presentations. They manage relationships with key agencies and providers to drive membership growth within an assigned territory.
The Community Based Care Manager facilitates inter-disciplinary care team meetings and develops person-centered care plans to address the behavioral, physical, and social health needs of members. They conduct psychosocial assessments and coordinate services across various community settings to improve member outcomes and ensure access to care.
The intern will provide support on special projects, initiatives, and specific activities that vary by assignment. They will also participate in seminars to network with company leaders and gain real-world professional experience.
Collaborate with inter-disciplinary teams to develop and implement person-centered care plans that address physical, behavioral, and social determinants of health. Facilitate care coordination, conduct psychosocial assessments, and monitor member progress to ensure effective utilization of healthcare resources.
The role involves developing complex reports, dashboards, and data pipelines to support LTSS and Dual Eligible programs while driving operational efficiency. You will collaborate with cross-functional teams to translate business requirements into actionable insights using advanced statistical and BI tools.
The Member Health Assessor conducts health risk assessments and coordinates care plans for members to address their unique health needs. They maintain professional relationships with members and stakeholders while ensuring accurate documentation and process improvements within the care management program.
The Care Guide coordinates care for members by serving as a primary point of contact to identify needs, manage barriers, and facilitate transitions between care settings. They collaborate with inter-disciplinary teams to implement interventions, educate members on resources, and document all activities in compliance with company policies.
The intern will support actuarial tasks such as reserving, forecasting, benefit pricing, and rate analysis while completing a summer-long project. They will also collaborate with cross-functional teams to develop AI-enabled actuarial solutions to optimize financial performance.
The Medicare Sales Representative II is responsible for executing sales strategies and enrollment goals for Medicare Advantage products within an assigned territory. They serve as a subject matter expert, conducting community outreach and educational presentations while maintaining compliance with state and federal regulations.
The Business Analyst IV leads enterprise-level initiatives by shaping business strategy and driving alignment between organizational objectives and technology solutions. This role provides strategic oversight across programs, mentors staff, and leverages data to influence decision-making and business outcomes.
The Nurse Care Manager provides comprehensive care coordination, including in-home assessments, service authorization, and the development of patient-centered service plans. They collaborate with interdisciplinary teams and families to ensure safe, cost-effective care across various healthcare settings.
The Sales Strategy & Operations Manager will drive enrollment growth by developing market-specific strategies, managing sales analytics, and optimizing field execution. The role involves collaborating with cross-functional teams to improve sales productivity and ensuring the successful implementation of strategic initiatives.
The Rural Health Liaison conducts outreach activities and serves as a resource for members, providers, and community organizations to address rural health needs. This role facilitates education programs, supports policy development, and fosters relationships to improve health equity and outcomes.
The Manager oversees Integrated Care Duals Product Teams to coordinate member care, service delivery, and health benefits while ensuring compliance with state and accreditation requirements. They are responsible for monitoring clinical outcomes, managing staff performance, and collaborating with community partners to optimize resource utilization.
The Health Partner Network Manager is responsible for executing contracting strategies, managing provider recruitment, and ensuring compliance with regulatory requirements. They also analyze financial data to establish reimbursement rates and negotiate contracts with various healthcare providers.
The Community Health Worker coordinates care for members by engaging with them in various settings and assisting with care plan goals. They also provide health education, gather information for assessments, and support members in managing their health and wellness.
The Utilization Management Market Operations Manager oversees operational activities, including policy development, team metrics, and statutory reporting for specific lines of business. They drive process improvement, mentor clinical staff, and manage relationships with internal and external partners to ensure adherence to regulatory and accreditation standards.
The Managing Actuary leads a team to ensure compliance with actuarial standards while overseeing pricing, forecasting, and reserving processes. They provide strategic recommendations to leadership and manage actuarial models to support business goals and rate filings.
The associate serves as a dedicated operational advocate for brokers and agencies, managing complex pre and post-enrollment issues and service escalations. They are responsible for researching member inquiries, processing broker requests, and educating prospective members on health plan benefits and enrollment.
The Director of Actuarial Science guides strategic direction, oversees pricing and forecasting, and drives innovation through statistical modeling and AI-enabled solutions. They are responsible for ensuring regulatory compliance, managing actuarial teams, and providing insights to senior management to support corporate goals.
The Care Guide acts as a single point of contact to coordinate care for members, identifying needs and implementing interventions to improve health outcomes. They collaborate with care managers and providers to facilitate transitions of care and ensure members are supported and informed throughout their treatment journey.
Collaborate with inter-disciplinary teams to develop and implement person-centered care plans that address the physical, behavioral, and social determinants of health. Facilitate care coordination through regular assessments, provider communication, and community resource engagement to improve member health outcomes.
The Community Based Care Coordinator manages and coordinates care for dual-eligible beneficiaries by integrating health services and community resources. They conduct comprehensive assessments, develop individualized care plans, and collaborate with interdisciplinary teams to improve health outcomes.
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.
