Responsible for processing medical necessity reviews for behavioral health services and coordinating care for members. This includes performing prospective, concurrent, and retrospective reviews and assisting with discharge planning.
CareSource
49 Remote Job Openings at CareSource
Acts as a strategic advisor to resolve complex employee relations issues and strengthen organizational practices. Partners with leadership to implement ER strategies, conduct investigations, and drive change management initiatives.
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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a day 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.
Manager, Rapid Response & Incident Management Operations
CareSource
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Full Time
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a day ago
CareSource
Lead the Rapid Response and Incident Management teams to resolve member, provider, and regulatory escalations efficiently. Oversee the tracking of critical incidents and implement corrective action plans to ensure operational compliance.
The Tribal Liaison establishes and maintains partnerships with Tribes, Urban Indian Health Programs, and Indian Health Services in Nevada. The role focuses on enhancing physical and behavioral health for AI/AN communities through outreach and strategic collaboration.
Lead day-to-day LTSS service determination operations to ensure accurate, compliant, and member-centered translation of assessments into supports. Manage a team of professionals while partnering with clinical and compliance stakeholders to optimize workflows and regulatory alignment.
Health Plan Data Analyst III (Health Plan & Provider experience a must)
CareSource
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Full Time
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5 days ago
CareSource
Responsible for extracting, analyzing, and monitoring provider data to support business functions and enhance operational performance. The role involves managing Health Partner Lifecycle initiatives from concept to implementation and acting as a subject matter expert for provider data.
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.
Dir, Finance - Market(Must Live In Georgia And Preferred Experience in Managed Care)
CareSource
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Full Time
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7 days ago
CareSource
Provides financial oversight and leadership for the market, including comprehensive financial reporting and budget management. Collaborates with actuarial and risk adjustment teams to optimize revenue and manage cost drivers.
PI Medical Coding Reviewer III (CPC, RHIT or RHIA required)
CareSource
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Full Time
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7 days ago
CareSource
Supports complex medical record audit programs and manages disputes and escalations for pre-pay and post-paid processes. Provides leadership through mentoring analysts and coordinating training to identify improper coding and fraud.
Responsible for capturing, resolving, and reporting on complex claim adjustment requests and COB issues. Acts as a technical resource for training and collaborates with other departments to resolve payment errors and ensure regulatory compliance.
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.
Responsible for the strategic planning and execution of hospital and provider contracting to ensure optimal member access and financial performance. Oversees network operational strategy, reimbursement models, and maintains relationships with regulatory agencies like CMS and Medicaid.
Director Of Strategic Sourcing(Preferred Experience in Managed Care & AI)
CareSource
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Full Time
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12 days ago
CareSource
Oversee the enterprise strategic sourcing function across direct, indirect, and IT spend categories to deliver value and savings. Lead category councils and standardize vendor selection and contracting processes to ensure alignment with organizational goals.
Provides financial leadership and oversight for corporate budgeting, quarterly forecasting, and strategic financial planning. Acts as a strategic partner to business owners to drive cost savings, efficiency, and growth through detailed analysis and reporting.
Lead a team of IT professionals to design and deliver quality technical solutions aligned with business strategies and architectural standards. Manage relationships with business stakeholders, oversee project execution, and optimize the delivery of technology services.
Conduct systemic and targeted analysis to identify reimbursement errors and determine root causes for claims. Collaborate with IT and configuration teams to develop test scripts and ensure accurate payment implementation.
Conduct systemic and targeted analysis to identify reimbursement errors and determine root causes for claims. Collaborate with IT and configuration teams to develop business requirements and ensure comprehensive UAT test scripts.
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 collaborate with internal teams and vendors to implement process improvements.
Clinical Care Reviewer II - Must be Nevada Licensed and Work PST Hours
CareSource
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Full Time
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15 days 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.
Behavioral Health Medical Director - Clinical Appeals
CareSource
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Full Time
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20 days ago
CareSource
The Behavioral Health Medical Director ensures patient safety and safe prescribing practices for members with behavioral health diagnoses. This role involves leading clinical policy development, overseeing utilization management, and serving as a clinical liaison to state agencies and providers.
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.
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.
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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22 days 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.
Collaborates with inter-disciplinary teams to develop and implement person-centered care plans for members. Coordinates healthcare services, manages barriers to care, and provides clinical oversight to improve member health outcomes.
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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a month 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 Enterprise Medical Director oversees patient safety, clinical policy development, and quality improvement initiatives within the behavioral health market. They also provide clinical leadership, supervise medical directors, and conduct utilization management and peer-to-peer reviews.
The Behavioral Health Medical Director oversees patient safety, specifically regarding safe prescribing, and serves as the clinical lead for policy development and quality improvement initiatives. They also manage utilization reviews, represent the organization to external agencies, and provide clinical guidance to staff and providers.
The Clinical Psychologist provides behavioral health coverage determination for utilization management to ensure members receive appropriate and medically necessary care. They also serve as a clinical lead in developing evidence-based policies, participating in quality improvement initiatives, and representing the organization to providers and state agencies.
The Associate Medical Director provides clinical consultation, case reviews, and provider education to support behavioral health programs. They also participate in policy development, regulatory compliance, and investigations regarding fraud, abuse, and quality of care.
The Clinical Psychologist provides behavioral health coverage determination for utilization management to ensure members receive appropriate and medically necessary care. They also serve as a clinical lead in developing evidence-based policies and represent the organization to providers and state agencies.
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.
The Business Insights & Planning Analyst III coordinates the execution of diligence planning items and manages the due diligence workstream for the Business Development team. They also support acquisition planning activities and develop various materials for meetings and presentations.
Mom and Baby Care Manager - RN - Must reside in Nevada
CareSource
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Full Time
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2 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 Customer Account Manager is responsible for all customer-facing account management, implementation, and revenue growth activities for assigned accounts, applying a data-driven approach to increase service utilization and customer ROI. This role involves leading training, designing outreach strategies, monitoring utilization data, managing implementations, and leading governance meetings with executive stakeholders.
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.
This role leads specialized contracting efforts, handles unique contracting situations, and is responsible for tracking, inventory, and priorities within the Ohio market. The manager will also assist in developing team strategy, establishing goals, and leading cross-functional workgroups for priority contracts.
The Team Lead is responsible for the daily activities related to testing medical benefits, provider reimbursement, letters, claims workflow, and clinical editing, while also guiding the team's successful completion of tasks. This role involves prioritizing work, managing staff onboarding and development, tracking issues, and providing management with ticket dashboards and proactive resolution recommendations.
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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3 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.
