The Director of Utilization Management Operations manages departmental projects, ensures regulatory compliance, and oversees the standardization of evidence-based clinical practices. They lead collaboration across clinical teams, support new business implementation, and develop operational workflows to improve member outcomes.
The manager oversees the grievance, appeal, and state hearing teams to ensure regulatory compliance and timely resolution of issues. They are responsible for analyzing operational trends, developing staff, and implementing process improvements to support organizational goals.
The Healthcare Analyst II analyzes healthcare utilization to identify patterns, outliers, and opportunities for medical cost reduction. They also develop tools to compare market performance and provide actionable recommendations to improve network provider performance.
The Digital Product Designer III leads user research and experience design activities to improve member- and provider-facing digital products. They partner with cross-functional teams to translate customer insights into actionable design solutions while ensuring alignment with enterprise standards.
The Technical Delivery Lead is responsible for providing technical leadership and governance for release, deployment, and environment management services. They will drive the full development lifecycle, oversee complex system architecture, and implement AI-enabled capabilities to improve organizational productivity.
The Director leads regulatory, compliance, and accuracy assurance activities while serving as the primary liaison between the Operations division and enterprise partners. They are responsible for driving operational transformation through automation, auditing, and the implementation of effective control frameworks.
The analyst is responsible for establishing and maintaining reconciliation, validation, and control processes for finance data consumed from the data warehouse. They will investigate variances, document control exceptions, and support internal and external audits to ensure data accuracy and compliance.
The Data Scientist I supports the design and validation of predictive and machine learning models to inform business processes. They are responsible for mining large datasets, developing algorithms, and communicating analytical insights to key stakeholders.
Review and process traditional and specialty medication prior authorization requests, including routing cases requiring pharmacist review and ensuring inquiries are answered within mandated timeframes. Support providers, pharmacies, case managers, and member services by resolving pharmacy issues, documenting interactions, and responding to escalations.
The Community Based Care Coordinator serves as the primary point of contact for member assessment, person-centered planning, and service coordination. They monitor service delivery, facilitate transitions between care levels, and provide health education to members and their families.
Lead the preparation and analysis of accurate cost reports, identify trends and reimbursement opportunities, and ensure compliance with company policies and regulatory requirements. Improve reporting systems and processes, communicate findings to stakeholders, and support management planning through reports and presentations.
The Customer Care Specialist resolves routine service inquiries regarding claims, benefits, and eligibility while ensuring compliance with HIPAA and federal regulations. They are responsible for maintaining accurate documentation and building positive relationships with members and providers.
The Rural Health Liaison conducts outreach and provides resources to rural populations to address health needs and promote health equity. This role facilitates community education, supports provider recruitment, and collaborates with stakeholders to improve health outcomes.
The specialist is responsible for processing medical necessity reviews and authorizing home and community-based supports for complex populations. They also collaborate with care teams to manage discharge planning and ensure healthcare services are delivered cost-effectively.
The Manager of Clinical Appeals oversees all clinical appeals activities to ensure regulatory compliance and consistent service delivery. They analyze utilization data, manage provider interactions, and develop departmental policies to optimize workflows and member outcomes.
The Member Health Assessor conducts health risk assessments and coordinates care plan goals for members. They also provide health education and maintain accurate documentation within the Care Management program guidelines.
Research and develop medical, clinical, behavioral health, and reimbursement policies, ensuring they comply with applicable company, state, and federal requirements. Coordinate policy development and implementation with internal teams, subject matter experts, and business leaders, while monitoring regulatory changes and supporting governance workflows.
The associate serves as an operational advocate for brokers and agencies by resolving complex pre and post-enrollment issues and member inquiries. They also assist prospective members with health plan selection and enrollment while maintaining accurate records of all interactions.
Lead business analysis strategy across enterprise programs, aligning business and technology initiatives with organizational priorities and measurable outcomes. Advise executives on investments, requirements, risks, and portfolio decisions while establishing analysis standards, advancing technology-enabled practices, and mentoring teams.
Lead business analysis and cross-functional process improvement initiatives, including process redesign, feasibility and ROI assessments, and operational readiness for new systems and processes. Manage claim lifecycle performance and implementation activities, analyze operational data, advise leadership on change strategies, and mentor business operations analysts.
The Integrated Care Clinical Manager provides clinical care management and monitoring for dually-eligible enrollees with complex medical, behavioral, and social needs. This role involves leading interdisciplinary care teams, conducting home visits, and coordinating community resources to improve health outcomes and prevent hospital readmissions.
The Director of Actuarial Science leads strategic actuarial initiatives, including Medicaid forecasting, month-end close processes, and the development of statistical models. They are also responsible for mentoring staff, ensuring regulatory compliance, and integrating AI-enabled solutions into actuarial workflows.
The analyst serves as a subject matter expert for medical coding, overseeing audit programs and resolving complex provider claim issues. They also lead automation requirements for AI auditing workflows and collaborate with internal departments to drive process improvements and financial savings.
The Product Manager is responsible for defining the vision, strategy, and roadmap for assigned products while coordinating cross-functional teams through implementation and stabilization. They also establish governance frameworks, manage vendor relationships, and ensure initiatives meet regulatory and business objectives.
The Product Manager is responsible for defining the strategy, vision, and roadmap for enterprise data migration and transformation initiatives. They coordinate cross-functional teams to ensure successful delivery, governance, and transition of products to operational ownership.
The Care Coordinator serves as the primary point of contact for members, assisting them in navigating health plan services and coordinating care through community-based outreach. They lead interdisciplinary care teams to develop member-centered care plans and ensure continuity of service through accurate documentation and provider collaboration.
The Integrated Care Clinical Manager provides clinical care management and monitoring for dually eligible enrollees with complex medical and social needs. They lead interdisciplinary care teams to develop holistic care plans and coordinate services across healthcare providers and community resources.
The Director leads the design and implementation of automation and artificial intelligence capabilities to optimize claims operations. They are responsible for managing vendor performance, overseeing operating budgets, and driving process improvements to enhance claims accuracy and efficiency.
The Integrated Care Clinical Manager provides clinical care management and monitoring for dually eligible enrollees with complex medical, behavioral, and social needs. They lead interdisciplinary care teams to develop holistic care plans and coordinate services across healthcare providers and community resources.
The Integrated Care Clinical Manager provides clinical care management and monitoring for dually eligible enrollees with complex medical and social needs. This role involves leading interdisciplinary care teams, conducting home visits, and coordinating community resources to improve health outcomes.
The Community Marketing Representative II supports enrollment and retention strategies by conducting educational outreach and managing relationships with community organizations and government agencies. They are responsible for driving membership acquisition, managing lead generation, and ensuring all marketing activities comply with state and federal regulations.
The Senior Director of Actuarial Science sets the strategic direction for actuarial functions, including pricing, forecasting, and performance monitoring. They lead a team of actuaries to ensure regulatory compliance and provide expert guidance on financial drivers and statistical modeling to support corporate goals.
The Director of Finance provides financial oversight, leadership, and reporting for the market, ensuring proactive collaboration across departments. Key duties include managing IBNR models, supporting monthly close processes, coordinating revenue maximization efforts, and overseeing departmental staff.
The Pharmacy Technician II handles member and provider calls related to clinical pharmacy campaigns while performing clerical and technical duties. They are responsible for accurately entering data, collaborating with internal departments, and ensuring a positive member experience.
The Manager of Utilization Management oversees all utilization activities to ensure consistency, regulatory compliance, and the achievement of utilization targets. They are responsible for managing pre-determination processes, analyzing utilization data, and collaborating with providers to optimize member quality of care.
The Systems Analyst III leads research and analysis to identify system impacts, dependencies, and business process improvements. They serve as a liaison between technical teams and stakeholders to translate business needs into clear agile stories and features.
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 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 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 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 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 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 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 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 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 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.
