The Program Manager coordinates programs for member benefits like DME and home modifications while monitoring vendor performance and operational KPIs. They collaborate with internal and external stakeholders to ensure regulatory compliance and drive continuous improvement in member service delivery.
CareSource
42 Remote Job Openings at CareSource
The Medical Director provides clinical consultation, case reviews, and prior authorization services while supporting staff through training and performance evaluations. They also participate in quality improvement initiatives, policy development, and regulatory compliance activities to ensure high standards of care.
The Pharmacist I is responsible for reviewing Prior Authorization requests using clinical expertise and formulary management guidelines. They also engage in peer-to-peer discussions with providers and collaborate with pharmacy technicians to ensure operational efficiency.
Clinical Care Manager - Massachusetts - East Longmeadow - 5K Sign On Bonus
CareSource
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Full Time
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6 days ago
CareSource
The Clinical Care Manager coordinates complex medical, behavioral, and social care for dually-eligible enrollees by conducting home visits and leading interdisciplinary care teams. They act as a liaison between healthcare providers and community resources to ensure seamless care transitions and improved health outcomes.
The Provider Relations Account Manager is responsible for managing and maintaining relationships with network providers to drive operational excellence and satisfaction. This role acts as a liaison between providers and internal stakeholders to ensure compliance, facilitate education, and resolve operational issues.
The Clinical Care Reviewer II processes medical necessity reviews for healthcare services and coordinates care transitions for members. They also monitor the delivery of healthcare services and provide clinical guidance to non-clinical and LPN staff.
The Onboarding Specialist serves as the primary contact for new members transitioning to health plans, coordinating existing and new healthcare services. They educate members on plan offerings and liaise between internal and external providers to ensure continuity of care.
Mom and Baby Care Manager - Social Worker Pacific Time Zone Required
CareSource
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Full Time
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11 days ago
CareSource
Collaborates with inter-disciplinary teams to develop and implement person-centered care plans for mothers and babies. Coordinates healthcare services, manages barriers to care, and ensures effective utilization of community and medical resources.
Mgr, Ohio Market Contracting- Managed Care- Healthcare-Leadership Experience
CareSource
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Full Time
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13 days ago
CareSource
Lead specialized contracting efforts and negotiations for the Ohio market while managing a team of direct reports. Responsible for tracking priorities, developing strategic directions, and coordinating with internal business partners to ensure timely contract implementation.
Develop and manage complex data sets and interactive dashboards to track KPIs for LTSS and Dual Eligible programs. Collaborate cross-functionally to optimize business processes and provide actionable insights for executive leadership.
Drive end-to-end process transformation in Claims Operations by leveraging AI and automation to improve efficiency and reduce costs. Manage the full lifecycle of the automation pipeline, from intake and design to implementation and value realization.
The analyst ensures the accuracy of vendor payment processes by auditing medical records and diagnostic codes for medical necessity. They identify root causes of claims issues and lead process improvement initiatives with internal teams and vendors.
Acts as a strategic partner to senior leaders to align HR initiatives with business objectives and organizational culture. Responsible for guiding leadership development, succession planning, and analyzing employee engagement trends to improve workplace effectiveness.
Manage large-scale LTSS and Dual Eligible portfolio programs to ensure successful delivery and alignment with strategic business objectives. Lead cross-functional coordination, manage program budgets up to $10M, and maintain governance through reporting and stakeholder engagement.
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.
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.
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 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 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.
Senior Director, Clinical Data Governance and Integration
CareSource
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Full Time
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a month 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.
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.
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.
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 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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a month 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.
VP, Network Strategy & Contracting(Preferred Managed Care Experience And Must Live In Nevada)
CareSource
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Full Time
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2 months 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.
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.
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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3 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.
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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5 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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7 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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7 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.
