The Care Navigator assesses member needs and coordinates personalized care plans to improve healthcare outcomes and access. They provide ongoing advocacy, resource support, and telephonic outreach to foster care members and their families.
The Senior Quality Auditor develops and implements business solutions by auditing and validating claims to ensure compliance with corporate policies and regulatory guidelines. They also research discrepancies, document audit results, and provide data to support training programs and quality improvement initiatives.
The analyst will design, build, and support complex data solutions, reporting, and automations while serving as a subject matter expert for business systems and claims data. They will also lead technical initiatives, manage project milestones, and partner with cross-functional teams to resolve production issues and ensure data accuracy.
The Case Auditor conducts comprehensive audits of care management records to ensure compliance with regulatory standards and internal policies. They also collaborate with leadership to implement corrective action plans and drive continuous quality improvement initiatives.
The Vendor Relations Manager oversees third-party evaluations and manages relationships with delegation partners to ensure performance and financial standards are met. They act as a primary link between internal departments and delegated entities, facilitating service launches and ongoing operational interactions.
The People Relations Partner serves as a trusted advisor to leaders and employees, managing employee relations cases from intake through resolution. They provide guidance on workplace matters, policy interpretation, performance management, and disciplinary processes while ensuring compliance with employment laws.
Performs concurrent reviews to evaluate medical necessity, member health, and appropriate level of care. Collaborates with healthcare providers and medical directors to ensure quality care and effective discharge planning.
The analyst will monitor and track state regulations, contract amendments, and regulatory guidance to ensure company compliance. They will collaborate with Legal, Policy, and Government Relations departments to synthesize requirements and implement necessary changes.
The Care Manager RN develops, assesses, and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. They collaborate with providers and families to create personalized care plans, monitor member status, and address social determinants of health.
The manager will oversee business processes related to risk adjustment and quality improvement for assigned products and plans. They are responsible for developing operational workflows, managing risk adjustment strategies, and preparing performance dashboards for senior management.
The intern will support business projects and learn about various processes and functions within the Managed Care industry. Responsibilities include conducting research on legal and regulatory topics and attending professional development training.
The Clinical Extern will shadow preceptors and participate in projects to gain hands-on experience within the Managed Care industry. They will follow established procedures to learn about clinical services and support company processes.
The Care Coordinator II supports care management activities by performing member outreach via phone or home visits to engage individuals and discuss care plans. They coordinate services with healthcare providers and community partners to ensure continuity of care and maintain accurate member records.
The Provider Data Process Owner facilitates and leads complex, large-scale cross-functional initiatives to improve business processes and operational effectiveness. They are responsible for analyzing data, workflows, and policies to develop scalable improvements while ensuring alignment with strategic goals and stakeholder collaboration.
The Quality Practice Advisor fosters relationships with physician practices to educate them on HEDIS measures, risk adjustment, and medical documentation standards. They also collect and analyze performance data to identify improvement opportunities and ensure compliance with state and federal requirements.
The nurse analyzes prior authorization requests to determine medical necessity and appropriate level of care for foster care members. They coordinate with healthcare providers and interdepartmental teams to ensure timely service delivery and compliance with regulatory standards.
The Manager of Operations oversees business strategy and cross-functional departments to meet organizational objectives. They lead a team of analysts to develop regulated outbound communications and implement data-driven process improvements.
The Performance Monitor Specialist conducts clinical file assessments and audits care management interactions to ensure compliance with organizational and contractual standards. They also participate in the development of review tools and provide insights for clinical performance improvement.
The manager oversees intake, referral management, and insurance verification activities while implementing quality control and process improvements. They are responsible for setting performance expectations, ensuring compliance with regulations, and maintaining data integrity for patient admissions.
The Accreditation Specialist develops and coordinates delegation oversight mechanisms and maintains accreditation readiness schedules. They also create policies and procedures while conducting training programs to support NCQA and HEDIS activities.
The VP will lead the strategy, roadmap, and delivery of the enterprise Member Experience and Omnichannel Engagement portfolio to create seamless, personalized interactions. They will drive alignment across business, technology, and analytics teams to simplify engagement processes and improve overall member experience.
The VP of Enterprise Product Management will lead the strategy, roadmap, and delivery of the Common Core platform to enable enterprise modernization and system interoperability. This leader will drive cross-functional alignment, establish product standards, and ensure the successful execution of transformational initiatives across the organization.
The Clinical Pharmacist will lead formulary, prior authorization, and clinical policy initiatives while supporting quality improvement and medication-related clinical programs. They will also analyze pharmacy performance data and collaborate with cross-functional teams to implement state-driven and quality-focused initiatives.
The supervisor oversees the utilization management team, ensuring adherence to clinical review standards, compliance, and quality efficiency. They also collaborate with senior management to develop policies and provide coaching to team members to facilitate effective healthcare service delivery.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to engage adolescents in foster care. They coordinate care plans, facilitate services with healthcare providers, and maintain accurate member records in compliance with regulatory standards.
Design, implement, and monitor IT controls for core systems while conducting risk assessments to protect sensitive data. Serve as a liaison between auditing bodies, IT security management, and business stakeholders to ensure compliance with industry standards.
Lead a team in the strategic and operational execution of Medicare initiatives while managing complex budgets and cross-functional projects. Collaborate with finance and analytics teams to develop business cases, monitor performance, and ensure alignment with regulatory and industry standards.
The Vice President of Clinical Operations oversees and directs all clinical operations, including care management and utilization management, to ensure the delivery of cost-effective and clinically appropriate services. They are responsible for establishing strategic vision, monitoring performance metrics, managing budgets, and driving staff development initiatives.
The Care Manager develops, assesses, and facilitates complex care management activities for members with mental and behavioral health needs. They coordinate care plans, collaborate with providers and community resources, and provide education to members and their families.
The Medical Director assists the Chief Medical Officer in directing medical management, quality improvement, and credentialing functions for the business unit. They provide medical leadership for utilization management, cost containment, and clinical quality improvement initiatives while collaborating with clinical teams to optimize patient outcomes.
The Senior Director of Product Implementation is responsible for guiding global product strategy, roadmaps, and end-to-end governance from concept to production. They will lead cross-functional teams to translate business needs into actionable product improvements while ensuring financial efficiency and ROI.
The Project Manager will oversee cross-functional teams to deliver strategic objectives and manage the full project life cycle, including requirements gathering and budget oversight. They are also responsible for maintaining compliance documentation, managing CMS-related systems, and facilitating communication between stakeholders.
The supervisor oversees behavioral health utilization review clinicians to ensure adherence to quality, efficiency, and regulatory standards. They also manage team performance, facilitate process improvements, and act as the primary contact for escalated care issues.
The Clinical Review Nurse performs concurrent reviews to evaluate medical necessity, acuity levels, and the appropriateness of care settings for members. They also collaborate with medical directors and healthcare providers to facilitate effective discharge planning and ensure high-quality care delivery.
Performs concurrent reviews to evaluate medical necessity, acuity levels, and appropriate care settings for inpatient members. Collaborates with healthcare providers and medical directors to ensure continuity of care and effective discharge planning.
The Senior UAS LTSS Assessor performs care management duties, including conducting UAS assessments and developing personalized care plans for high-acuity members. They collaborate with healthcare providers and caregivers to ensure quality, person-centered care while monitoring member status and compliance with regulations.
The assessor performs care management duties to evaluate the medical and service needs of high-acuity members, developing and monitoring personalized long-term care plans. They also act as a liaison between members, families, and healthcare providers to ensure the delivery of high-quality, cost-effective care.
Lead clinical coding compliance nurses and non-clinical staff through the code editing adjudication process including prepay compliance and appeals. Serve as a health plan account liaison to resolve escalated inquiries and ensure production standards are met.
The Senior Manager will oversee revenue forecast functions, membership reporting, and multi-year projection models. They are also responsible for managing the month-end closing process and leading a team of financial analysts to drive continuous reporting improvements.
The Care Manager develops and facilitates complex care management activities for members with mental and behavioral health needs, including creating personalized care plans. They also coordinate services between members, families, and providers while monitoring clinical outcomes and ensuring regulatory compliance.
The Senior Manager oversees internal and external cost recovery and cost containment initiatives to meet targeted project metrics and savings goals. They also collaborate with national vendors, streamline processes, and present reporting packages to senior management regarding financial performance.
Retain members in an assigned territory through calls, community outreach, events, and home visits, while explaining Wellcare products and helping members resolve questions and concerns. Document interactions and member account updates, meet production and quality standards, and comply with regulatory, audit, and corporate policies.
Retain members in an assigned territory through phone and in-person outreach, home visits, community events, and member education about Fidelis Care products. Resolve member inquiries, document interactions in Salesforce and Facets, maintain member relationships, and comply with regulatory and corporate policies.
Lead retention performance managers in developing and implementing strategies to reduce Medicare member disenrollment. Analyze retention trends, collaborate across teams to improve member experience, and oversee beneficiary education programs and retention initiatives.
The role involves assessing and coordinating medical and support services for high-acuity long-term care members to ensure quality, person-centered care. Responsibilities include developing personalized care plans, conducting field assessments, and collaborating with healthcare providers and families to meet member goals.
The Care Manager develops and facilitates complex care management activities for members with mental and behavioral health needs, including creating personalized care plans. They also coordinate services between members, families, and providers while monitoring clinical outcomes and ensuring regulatory compliance.
The manager will oversee compliance department functions, including auditing, monitoring, and ensuring adherence to federal, state, and local regulatory requirements. They are responsible for managing contract deliverables, implementing corrective action plans, and facilitating compliance training for employees.
The manager will lead the development and implementation of clinical and operational quality programs while collaborating with cross-functional teams to improve standards and workflows. They are responsible for overseeing Performance Improvement Projects, conducting needs assessments, and providing technical expertise to support strategic healthcare initiatives.
The Program Manager will oversee cross-functional programs, manage recovery operations, and facilitate project execution to meet strategic business objectives. They are responsible for monitoring performance metrics, identifying risks, and providing executive-level reporting to stakeholders.
The Program Manager will lead cross-functional initiatives including COB, TPL, and Subrogation projects while managing vendor implementations and operational enhancements. They are responsible for gathering requirements, creating project plans, and ensuring timely execution of strategic priorities across multiple health plans.
The Care Manager develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. They coordinate care plans, monitor member status, and collaborate with providers to address unmet needs and social determinants of health.
Lead and execute the organization's digital quality measurement strategy to modernize clinical data collection, validation, and reporting. Collaborate with internal and external teams to improve HEDIS performance, Medicare STARS ratings, and overall quality improvement initiatives.
Manage daily provider data management operations, including data entry, validation, and the resolution of complex data issues. Lead team workflows, monitor performance against quality benchmarks, and facilitate meetings with health plan representatives.
The Community Relations Coordinator will develop and implement community outreach plans while building relationships with local organizations to support member growth. They will also coordinate health education presentations and represent the Health Plan at various community and health events.
The Medical Director assists in directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. They provide medical leadership for utilization management, cost containment, and perform medical reviews for complex or experimental services.
The coordinator assesses member needs to develop and monitor personalized long-term care plans while facilitating access to community resources. They also educate members and caregivers on healthcare benefits and maintain documentation to ensure compliance with regulatory standards.
The coordinator assesses and develops holistic care plans for long-term care members while educating families on available services. They also monitor member outcomes and collaborate with healthcare providers to ensure accessible and cost-effective care.
The manager will oversee claims research and analysis, identifying process improvements and root causes to enhance operational performance. They are responsible for mentoring business analysts and implementing data-driven solutions across cross-functional teams.
The Clinical Pharmacist will develop and maintain clinical formularies, policies, and quality initiatives to support decision-making. They will also monitor prior authorization requests and collaborate with internal departments to improve pharmacy performance and patient outcomes.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to facilitate continuity of care. They coordinate services with healthcare providers and community partners while maintaining accurate member records in compliance with regulatory standards.
The Care Coordinator II supports care management activities by performing member outreach via phone or home visits to ensure continuity of care. They coordinate care plans, document member needs, and facilitate communication between healthcare providers, community partners, and members.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to facilitate continuity of care. They coordinate services with healthcare providers and community partners while maintaining accurate member records in compliance with regulatory standards.
The coordinator supports administrative care management activities by performing outreach, scheduling services, and resolving member or provider inquiries. They also maintain non-clinical member records and facilitate the connection of members to health plan and community resources.
The Senior Portfolio Optimization Process Owner is responsible for defining and executing Strategic Portfolio Management (SPM) processes to align initiatives with organizational objectives. They will drive data-driven decision-making, optimize process efficiency, and provide actionable insights to executive leadership to ensure portfolio health and value realization.
The Director of Quality Medicare Strategy leads the development of multi-year Medicare Stars performance strategies and oversees geographic market expansion. This role involves collaborating with cross-functional teams to implement innovations and drive improvements in quality outcomes and member experience.
The role involves developing and coordinating holistic care management plans to ensure quality healthcare outcomes for long-term care members. You will also educate members and their families on available services while monitoring care plans and collaborating with healthcare providers.
The Care Manager develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. They coordinate care plans, provide education to families, and collaborate with providers to address unmet needs and barriers to care.
The manager oversees the care management team to ensure high-quality, cost-effective healthcare outcomes while maintaining compliance with federal and state regulations. They are responsible for managing complex cases, staff caseloads, and implementing policies to improve member and provider experiences.
Supervises the utilization management team to ensure appropriate care and adherence to performance, compliance, and quality standards. Collaborates with senior management to develop policies and provides coaching to team members to facilitate process improvements.
The Claims Auditor performs quality audits on claims processes to ensure standards are met and identifies trends or errors for management. They provide feedback and coaching to examiners while recommending process improvements to enhance productivity and accuracy.
The Senior Manager oversees system and business requirements for new and existing markets, ensuring performance meets all health plan and provider contract standards. They are responsible for managing system configurations, reporting deliverables, and leading special projects to improve organizational efficiency.
Develop and oversee the enterprise pharmacy benefit management program to ensure clinical quality, financial performance, and regulatory compliance. Lead cross-functional teams to execute pharmacy strategies, manage vendor relationships, and optimize drug pipeline and formulary performance.
Manage delegated healthcare vendor relationships, contracts, service workflows, and performance, including SLA dashboards, scorecards, corrective action plans, and regular governance meetings. Resolve vendor, member, provider, and claims issues while coordinating with internal teams and ensuring operational integrity and compliance with policies, contracts, and state guidelines.
Manage complex projects throughout their full life cycle, including planning, requirements, resources, budgets, execution, deployment, and closure. Coordinate cross-functional stakeholders, communicate project status, mitigate risks, maintain documentation, and ensure deliverables meet quality standards.
Assess members’ healthcare needs, access barriers, and social determinants of health, then develop and coordinate personalized care plans with members, families, providers, and community resources. Monitor progress, provide education and follow-up, document care activities, and identify opportunities to improve quality and cost-effective care.
Promote health plan products and improve access to healthcare through community outreach, education, enrollment and member support across an assigned North Carolina territory. Build relationships with community organizations and stakeholders, coordinate outreach events, and maintain compliant event documentation, reporting, budgets and branding standards.
Oversee health plan compliance, regulatory submissions, state regulator relationships, audits, and enterprise risk management. Lead internal audits and corrective action plans, ensure contract and regulatory requirements are met, and manage compliance oversight of material subcontractors.
Performs concurrent reviews of inpatient admissions to evaluate medical necessity, acuity levels, and appropriate care settings. Collaborates with medical staff and providers to facilitate discharge planning and ensure continuity of care according to clinical guidelines.
The Senior Director leads analytic service delivery by aligning strategic objectives with tool development and managing cross-functional analytic teams. This role focuses on utilization management data to support regulatory reporting and provides actionable business insights to executive leadership.
Coordinate and negotiate hospital, physician, and ancillary service agreements in accordance with corporate and state guidelines. Manage provider network options, process agreements through the SharePoint system, and ensure timely communication with internal and external stakeholders.
The Behavioral Health Clinical Liaison serves as a primary point of contact for external providers regarding clinical information and medical management operations. They are responsible for assessing clinical records, facilitating provider education, and analyzing program data to improve quality and member outcomes.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to engage members and discuss care plans. They coordinate services with healthcare providers and community partners to ensure continuity of care and member satisfaction.
The Care Coordinator II supports care management activities by performing member outreach via phone or home visits to facilitate service delivery and continuity of care. They coordinate care plans with healthcare providers and community partners while documenting member needs and progress in accordance with regulatory standards.
The Senior Communications Specialist manages the creation of the HEDIS Provider Toolkit and supports the overarching communications practice. They are responsible for developing, reviewing, and revising health-related materials while ensuring compliance with regulatory and internal standards.
The Care Manager develops and facilitates complex care management activities, including personalized care plans and education for members and their families. They also coordinate with providers and community resources to address member needs and ensure access to appropriate healthcare services.
The Curriculum Designer will design, implement, and maintain training resources while developing instructional materials to support functional teams. They are also responsible for conducting training program reviews and assessing individual knowledge and quality results.
The Quality Practice Advisor fosters relationships with physician practices to educate them on HEDIS measures, risk adjustment, and medical documentation standards. They also collect and analyze performance data to identify improvement opportunities and ensure compliance with state and federal regulations.
The Care Manager develops, assesses, and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes. They coordinate care plans, monitor member status, and collaborate with providers and families to address unmet needs.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to facilitate service delivery and continuity of care. They also document care plans, coordinate with healthcare providers, and provide education on benefits and resources to members.
The Care Navigator develops and coordinates personalized care plans to improve health outcomes for foster care children. They provide telephonic support, advocate for member needs, and facilitate access to community resources and healthcare services.
Develop and maintain strategic partnerships with provider networks to advance value-based care initiatives and improve performance. Serve as a subject matter expert to provide data-driven insights, operational support, and training to provider organizations.
The Senior Actuary will conduct financial analysis, pricing, and risk assessment while supporting the Risk Adjustment team through modeling and data validation. They will also act as a point of contact for assigned markets and apply statistical principles to calculate financial outcomes.
The Director of Operations leads the development and execution of operational strategies and process improvements to support enterprise product growth. They serve as a primary liaison between product leadership and shared services to ensure alignment, timely decision-making, and operational readiness.
The Care Navigator assesses member needs and coordinates personalized care plans to ensure access to high-quality, cost-effective healthcare. They also provide psychosocial support and educate members and their families on available resources and benefit options.
The Care Manager develops, assesses, and facilitates complex care management activities for members with mental and behavioral health needs. They coordinate care plans, monitor clinical outcomes, and provide education to members and their families to ensure accessible and effective healthcare services.
The Director provides strategic and operational insights to senior leadership to drive market growth and key organizational initiatives. They act as a liaison between the President and various departments while managing special projects and overseeing the development of business review materials.
The Senior Care Manager assesses, plans, and implements complex care management activities to ensure quality, cost-effective healthcare outcomes for members. They also collaborate with providers and caregivers to develop personalized care plans and provide ongoing monitoring and education.
The Medical Director assists in directing medical management, quality improvement, and credentialing functions while providing leadership for utilization management and cost containment activities. They also collaborate with clinical teams and providers to review complex cases, optimize patient outcomes, and implement performance improvement initiatives.
Research and interpret healthcare regulations, legislation, and contractual requirements, then communicate their operational impact through summaries, guidance, policies, procedures, and job aids. Liaise with state Medicaid regulators, coordinate regulatory communications and audit deliverables, and work with internal and external stakeholders to track implementation and resolve compliance issues.
The manager will identify training needs and develop educational programs to enhance the performance and quality of corporate and field staff. They are responsible for analyzing program effectiveness, managing budgets, and overseeing cross-functional training initiatives.
The Compliance Officer ensures the organization adheres to state and federal health insurance regulations, including Medicare and Medicaid requirements. They are responsible for developing compliance policies, conducting audits, and managing strategic relationships with legislative policymakers.
The Associate Actuary will conduct strategic analysis, pricing, and risk assessment to estimate financial outcomes while managing actuarial reports. They will also build and support planning tools to aid in corporate strategy and Medicare strategic initiatives.
The coordinator connects members to community resources and provides support to the care team to facilitate effective care management. They conduct non-clinical health and environmental assessments through home visits and outreach to assist members in accessing necessary services.
The clinician performs clinical reviews to assess the medical appropriateness of mental health and substance abuse services. They also conduct prior authorizations, concurrent reviews, and engage with providers to ensure efficient care delivery.
Serve as the primary contact and liaison for contracted providers, resolving provider issues and communicating claims, policy, and demographic updates. Manage network performance through consultative account management, provider education, and improvement plans focused on quality, risk, cost, and utilization.
Lead Medicare strategic analysis and planning, develop and support actuarial tools and processes, and review and certify Medicare Advantage bids when eligible. Oversee health plan experience and pricing, assess risks and legislative impacts, present findings and recommendations, and train and develop direct reports.
Manage provider relationships across the assigned Alabama territory, serving as the primary contact and coordinating issue resolution between providers and the health plan. Evaluate network performance and develop improvement plans focused on quality, cost, utilization, and contract incentives, while educating providers and completing assigned projects.
The Clinical Investigator audits medical records and claims data to identify inappropriate billing practices, fraud, and abuse. They also recommend preventative measures and policy changes while consulting with investigators to analyze billing patterns.
The Provider Engagement Account Manager maintains partnerships between the health plan and provider networks to ensure high-quality care delivery. They act as a liaison to resolve provider issues, educate on policies, and drive performance improvements in quality and cost utilization.
Develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. Collaborates with providers and families to create personalized care plans and monitors progress toward health goals.
Develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. Collaborates with providers and families to create personalized care plans and monitors progress toward health goals.
Conduct fraud, waste, and abuse investigations by analyzing claims data, medical records, and provider information to identify misconduct. Prepare detailed investigative reports and collaborate with internal and external stakeholders to support case resolution and program integrity.
The Quality Improvement Coordinator II conducts compliance reviews, medical record audits, and utilization reviews for delegated entities. They also act as a liaison for clinical initiatives, investigate quality of care complaints, and develop corrective action plans.
The Director of Government Affairs coordinates state government relations, legislative activities, and regulatory compliance efforts. They are responsible for setting legislative priorities, lobbying state agencies, and representing the company to health plan associations.
The Program Manager IV coordinates the implementation of regulatory requirements and manages enterprise-scale healthcare data programs. They are responsible for overseeing program planning, budget management, and delivering executive-level communications to facilitate cross-functional project success.
The specialist manages provider network data, ensures accurate claims payment, and serves as the primary liaison for assigned physician groups and ancillary providers. They are responsible for resolving complex contract issues, maintaining provider databases, and providing education to network partners.
The manager leads provider data inventory, quality, and production while driving process improvements and operational excellence. They oversee project requirements, manage staff performance, and act as the primary contact for internal departments regarding business application changes.
The Senior Consumer Experience Analyst utilizes analytical techniques and consumer research data to support organizational initiatives and improve business outcomes. They are responsible for designing workflows, managing analytics resources, and providing actionable recommendations based on consumer-centric campaign performance.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to facilitate service delivery. They coordinate care plans, document member needs, and collaborate with healthcare providers to ensure continuity of care.
Interns will contribute to various projects across finance, accounting, and audit departments to support business strategy and financial performance. They will apply academic knowledge to real-world business challenges while developing professional competencies through training and mentorship.
Interns will contribute to various strategic projects across multiple business functions within the managed care industry. They are responsible for researching industry topics, managing project status updates, and supporting organizational goals through academic application.
Interns will support strategic initiatives to improve business performance, operational efficiency, and the experience of members, providers, and employees. They will contribute to projects across various functions while applying academic knowledge and communicating project status to management.
Interns will contribute to projects that support business operations and financial forecasting within the Managed Care industry. They will apply quantitative and problem-solving skills to real-world challenges while communicating project status to mentors and management.
Interns will contribute to projects across various data and analytics teams to support business decisions within the Managed Care industry. Responsibilities include researching legal and regulatory topics, communicating project results to management, and attending professional development training.
The Care Manager performs assessments, planning, and coordination of medical services for post-discharge members to ensure quality and cost-effective care. They also conduct medication reconciliation and facilitate transitions between primary care physicians, specialists, and community resources.
The RN performs care management duties to assess and coordinate medical and support services for high-acuity populations. They develop personalized care plans, educate families, and collaborate with healthcare providers to ensure high-quality, person-centered care.
The role involves maintaining partnerships between the health plan and provider networks while managing performance through consultative account management. Responsibilities include resolving provider issues, educating providers on policies, and driving improvements in quality and cost utilization.
The Provider Engagement Account Manager maintains partnerships between the health plan and provider networks to ensure high-quality care delivery. They act as a primary liaison to resolve provider issues, manage network performance, and drive improvements in quality and cost utilization.
Oversee the implementation of assigned programs and lead initiatives to improve service delivery and outcomes for specific populations. Develop and track outcome measures, analyze data, and represent the company in community and state meetings.
The Senior Actuarial Analyst will perform financial analysis, forecasting, and risk assessment to support Medicare Advantage performance. They will develop quarterly medical cost forecasts and communicate analytical findings to various stakeholders.
The clinician performs utilization reviews for Applied Behavioral Analysis (ABA) services to ensure medical appropriateness and clinical effectiveness. They also analyze member data, interact with healthcare providers, and provide education to families regarding the utilization process.
The RN performs care management duties to assess and coordinate medical and supporting services for complex, high-acuity pediatric populations. They develop personalized care plans, educate families on benefit options, and collaborate with healthcare providers to ensure high-quality, person-centered care.
The Senior LTSS Service Care Manager assesses and coordinates medical and support services for complex pediatric populations to ensure high-quality, cost-effective care. They develop personalized care plans, monitor member status, and collaborate with families and providers to facilitate appropriate service delivery.
The Provider Engagement Account Manager maintains partnerships between the health plan and provider networks to ensure high-quality care delivery. They act as a primary liaison to resolve provider issues, manage network performance, and drive improvements in quality and cost utilization.
The clinician performs clinical reviews to assess the medical appropriateness of mental health and substance abuse services. They also conduct prior authorizations, concurrent reviews for inpatient care, and engage with providers to improve treatment efficiency.
The clinician performs utilization reviews of Applied Behavioral Analysis (ABA) services to ensure medical appropriateness and clinical effectiveness. They also analyze behavioral health data and provide education to members and families regarding the utilization process.
The Director oversees the implementation of products and plans into Claims business units, ensuring alignment with corporate strategies and operational goals. They are responsible for directing claims business implementations to meet budget, timeline, and scope requirements while managing adherence to standard processes.
The Care Navigator develops and coordinates personalized care plans to improve healthcare outcomes for members, particularly those in maternal health populations. They act as an advocate and resource coordinator, ensuring members have timely access to necessary services and community support.
The clinician performs clinical reviews to assess the medical appropriateness of mental health and substance abuse services. They also conduct prior authorizations, concurrent reviews for inpatient care, and engage with providers to improve care efficiency.
The Care Manager develops, assesses, and facilitates complex care management activities for members with mental and behavioral health needs. They coordinate care plans, collaborate with providers, and provide education to members and their families to ensure high-quality, cost-effective healthcare outcomes.
The Transition Specialist oversees and manages the coordination of member transitions between various levels of healthcare services. They work with care teams to develop effective transition plans, educate members on service requirements, and ensure continuity of care.
Identify market trends and oversee quality improvement programs including HEDIS, CAHPS, and HOS strategies. Collaborate with stakeholders to analyze business issues, develop actionable insights, and ensure compliance with state and federal reporting requirements.
The Director will provide national expertise and thought leadership regarding foster care treatment, service needs, and evidence-based practices. They will lead workgroups, provide clinical training, and develop relationships with stakeholders to expand the business unit's national position.
The specialist will manage HEDIS projects, oversee vendor performance, and ensure data integrity for quality improvement initiatives. They will also assist in preparing for regulatory audits and implementing process improvements to streamline departmental functions.
The Care Manager develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. They coordinate care plans, collaborate with providers, and monitor member progress to ensure person-centered care and timely access to services.
Develops and coordinates personalized care plans for members, specifically supporting children in foster care. Facilitates access to healthcare providers and community resources while monitoring progress and maintaining compliance documentation.
Develops, assesses, and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. Coordinates care between members, families, and providers while maintaining documentation to ensure regulatory compliance.
The Community Relations Specialist leads activities to achieve membership and enrollment goals through marketing projects, community events, and provider outreach. They are responsible for developing business relationships, conducting presentations, and coordinating field marketing events to increase market visibility.
The Senior Director is responsible for managing a portfolio of medical management initiatives and implementing a comprehensive Health Equity Cultural Competency Program. They will lead cross-functional teams to improve clinical outcomes, manage vendor relationships, and develop data-driven strategies to address health disparities.
The Senior Director defines the strategy for capacity and scenario planning models to support claims operations and efficiency standards. They lead the workforce management team, prioritize strategic initiatives, and influence senior leadership to meet business objectives.
The supervisor will oversee the day-to-day operations of the network accounts department, ensuring compliance with health plan and state policies. They will also manage provider contracting activities, resolve escalated issues, and lead quality initiatives to improve health outcomes.
The VP of Network Strategy and Management Solutions will lead the development and execution of provider network strategies, including value-based contracting and network expansion. This role involves managing provider relationships, overseeing budgeting for network costs, and driving provider performance to improve healthcare quality and reduce costs.
The supervisor manages the workflow and daily activities of the recovery and revenue cycle management team to ensure performance standards are met. They are also responsible for investigating complex claims issues, monitoring reports, and overseeing employee management tasks such as hiring and coaching.
The manager will oversee the quality improvement program, specifically leading the state HEDIS audit and regulatory submission portfolio. They will also serve as a key escalation point for health plans and auditors while ensuring compliance with state and federal requirements.
The role involves operating, maintaining, and improving enterprise data security technologies to protect sensitive information. The engineer will independently resolve technical issues, perform system upgrades, and implement new security capabilities.
The Associate Actuary conducts financial analysis, pricing, and risk assessment to project Medicare Advantage performance. They support quarterly forecasting, Medicare bid certification, and provide data-driven recommendations to shape business strategy.
The Medical Director provides clinical leadership for utilization management, quality improvement, and cost containment activities while coordinating care for high-risk patients. They also collaborate with clinical teams and providers to review complex medical necessity appeals and ensure compliance with regulatory and accreditation standards.
The Care Manager develops and facilitates complex care management activities for members with mental and behavioral health needs. They conduct assessments, create personalized care plans, and coordinate with providers and community resources to ensure high-quality healthcare outcomes.
Performs access reviews, role provisioning, and supports Identity and Access Management systems through troubleshooting and process automation. Collaborates with cross-functional teams to design, implement, and maintain secure, high-availability IAM solutions.
The Senior Business Process Consultant leads cross-functional initiatives and develops business cases to drive performance improvement and financial gains. They are responsible for organizing work teams, facilitating consensus, and ensuring end-to-end policy and process integrity.
The Senior Manager oversees the maintenance of accurate financial records and leads financial analytic functions for inpatient claims. They are responsible for developing standardized review processes, preparing budgets and forecasts, and interpreting financial reports for senior management.
The Care Coordinator II supports care management activities by performing member outreach via phone or home visits to ensure continuity of care. They coordinate service plans, document member needs, and facilitate communication between healthcare providers, partners, and members.
The Care Manager performs assessments, planning, and coordination of medical services for post-discharge members to ensure quality and cost-effective care. They also conduct medication reconciliation and facilitate transitions between primary care physicians, specialists, and other support resources.
The Public Programs Specialist resolves member access to care issues and coordinates services with specialized public agency programs. They also serve as a liaison to external agencies and manage complex service coordination cases to ensure effective healthcare delivery.
The National Medical Director assists in directing medical management, quality improvement, and credentialing functions while providing leadership for utilization management and cost containment. They also collaborate with clinical teams and providers to optimize patient outcomes and ensure compliance with regulatory and accreditation standards.
The Community Relations Specialist leads marketing and outreach activities to achieve membership and enrollment goals within the Dallas-Fort Worth area. They are responsible for developing business relationships, coordinating community events, and acting as a liaison for market materials and sales strategies.
The Care Coordinator II supports care management activities by performing member outreach via phone or home visits to ensure continuity of care. They coordinate care plans, document member needs, and facilitate communication between healthcare providers, caregivers, and community partners.
The Strategy & Planning Manager provides strategic, operational, and administrative support to the Population Health and Clinical Operations Executive. This role involves managing action plans, coordinating executive communications, and facilitating cross-functional projects to ensure organizational objectives are met.
The Care Manager develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. They coordinate care plans, monitor member progress, and provide education to members and their families regarding disease processes and healthcare resources.
The Sales Representative will develop market penetration for Medicare products by conducting community outreach, home visits, and personalized appointments. They are responsible for identifying prospective enrollees, determining eligibility, and assisting members with health insurance enrollment and education.
The Associate Quality Practice Advisor educates community physician practices on HEDIS measures, medical record documentation, and coding standards to ensure compliance. They also collect and analyze provider performance data to identify improvement opportunities and support clinical wellness initiatives.
The Senior Medical Director will oversee clinical operations and provide strategic leadership for healthcare initiatives. They are responsible for ensuring high-quality patient care standards and regulatory compliance across the organization.
The Senior IAM Engineer designs, develops, and implements enterprise identity and access management solutions while serving as a technical escalation point. They are responsible for leading technical integrations, troubleshooting complex system behaviors, and contributing to the future-state IAM architecture and roadmap.
The Vice President of Product Strategy oversees the product development function, including formulating product vision, strategy, and roadmaps aligned with company goals. They drive digital and data-driven innovation while managing complex priorities across various business units and strategic partners.
The Senior Trainer is responsible for developing and administering universal training curricula and auditing tools for various departments. They will conduct training sessions, evaluate program effectiveness, and implement improvements based on audit results.
The Health Benefit Representative educates and assists individuals with enrolling in various health insurance plans through the NY State of Health Marketplace. They also support existing members with renewals, benefit education, and community outreach activities.
The Senior Director oversees the development and implementation of contracting activities, network development, and optimization initiatives across multiple product lines. They are responsible for executing network strategies that support organizational growth, regulatory compliance, and provider engagement.
The Vice President of Member Enrollment & Billing oversees regional billing and enrollment operations to ensure regulatory compliance and operational efficiency. This role involves developing strategic plans, managing departmental budgets, and fostering a high-performing team to drive revenue cycle excellence.
The Senior Actuarial Analyst assists in financial analysis, pricing, and risk assessment to estimate outcomes and support business decision-making. They are responsible for building actuarial models, evaluating healthcare cost trends, and communicating findings to executive stakeholders.
The Contract Negotiator V leads complex provider and vendor negotiations to strengthen strategic partnerships and support organizational affordability goals. They are responsible for managing implementation, conducting financial analyses, and reporting on the performance of designated agreements.
The Senior Infrastructure Security Engineer manages Attack Surface Management and Breach Attack Simulation programs to validate security controls and reduce risk. They collaborate across departments to monitor vulnerabilities, remediate security alerts, and maintain robust application security standards.
The Director of Clinical Training oversees all training activities, including curriculum development, facilitation, and the evaluation of training effectiveness and ROI. They collaborate with subject matter experts and HR to implement learning initiatives that support succession planning, performance management, and organizational effectiveness.
The officer serves as a partner between enterprise stakeholders and risk management to translate regulatory and security requirements into operational controls. They facilitate cross-functional initiatives to ensure audit-ready compliance while enabling risk-informed business decisions across technology and operational environments.
The manager will lead a team to investigate fraud, waste, and abuse while ensuring compliance with state and federal regulations. They are responsible for monitoring business processes, preparing saving reports, and developing educational materials for the health plan.
Develops and coordinates holistic care management activities for members with significant mental and behavioral health needs. Acts as a liaison and advocate while performing regular site visits to assess needs and facilitate community resources.
The role translates complex regulatory and contractual requirements into actionable, risk-informed analysis to support enterprise privacy and security. It serves as a Second Line of Defense advisory partner, developing executive-ready insights and ensuring regulatory requirements are operationalized across the organization.
The Enterprise Engagement Lead Analyst translates complex regulatory and contractual requirements into actionable, risk-informed analysis for the Enterprise Privacy & Security Risk Management team. This role serves as a Second Line of Defense advisor, developing executive-ready insights and ensuring regulatory obligations are effectively operationalized across the enterprise.
The Enterprise Engagement Lead Analyst translates complex regulatory and contractual requirements into actionable, risk-informed analysis for the Privacy & Security team. They serve as a Second Line of Defense advisor, developing executive-ready insights and ensuring regulatory obligations are operationalized across the enterprise.
The Enterprise Engagement Lead Analyst translates complex regulatory and contractual requirements into actionable, risk-informed analysis to support privacy and security operations. They serve as a Second Line of Defense advisor, developing executive-ready insights and maintaining requirement traceability across the enterprise.
The Enterprise Engagement Lead Analyst translates complex regulatory and contractual requirements into actionable risk-informed analysis for the Privacy & Security team. They serve as a Second Line of Defense advisor, developing executive-ready insights and ensuring regulatory obligations are effectively operationalized across the enterprise.
The Behavioral Health Medical Director assists in directing medical management, quality improvement, and credentialing functions while providing leadership for utilization review and cost-containment activities. They also collaborate with clinical teams to optimize care for high-risk patients and represent the business unit on medical policy matters.
The coordinator connects members to community resources and supports the care team by identifying support needs and providing health education. They conduct non-clinical assessments and outreach to help members navigate care services and resolve concerns.
The Lead Proposal Writer develops complex, high-scoring Medicaid RFP responses by collaborating with subject matter experts to translate policies into compelling narratives. They also serve as a functional area expert, mentor departmental staff, and manage project activities to support business growth.
Lead the development and execution of business development strategies to expand ICHRA adoption and drive organizational growth. Build and maintain executive relationships with brokers, employers, and key stakeholders while overseeing market expansion initiatives.
The manager will oversee regulatory audits and examinations for a regional portfolio of Medicaid health plans while leading a team of audit coordinators. They are responsible for ensuring audit readiness, managing documentation, and presenting audit outcomes to leadership.
The specialist leads the integrity and governance of corporate ethics and compliance programs while overseeing vendor relationships and contract lifecycles. They also manage regulatory updates and conduct audits to ensure adherence to government-sponsored healthcare program requirements.
Conduct fraud, waste, and abuse investigations by analyzing claims data, medical records, and provider information to identify misconduct. Prepare detailed investigative reports and collaborate with internal and external stakeholders to support case resolution and program integrity.
The Senior Director will develop and execute integrated multichannel marketing strategies to drive growth for the ICHRA insurance business. They will lead marketing teams and agency partners while fostering a data-driven, consumer-obsessed culture.
The Provider Quality Liaison connects with plan providers to share quality performance reports and collaborate on initiatives to improve HEDIS and member experience measures. They act as an ongoing resource for provider practices, resolving issues and developing action plans to support quality performance across various product lines.
The clinician performs clinical reviews to assess the medical appropriateness of mental health and substance abuse services. They conduct prior authorizations, concurrent reviews, and engage with healthcare providers to improve the quality and efficiency of care.
Conduct fraud, waste, and abuse investigations by analyzing claims data, medical records, and provider information to identify misconduct. Prepare detailed investigative reports and collaborate with internal and external stakeholders to support case resolution and program integrity.
The Vice President provides strategic and operational leadership for enterprise interoperability, ensuring secure and seamless healthcare data exchange across systems and stakeholders. They are responsible for developing roadmaps, managing vendor partnerships, and ensuring compliance with federal and state interoperability requirements.
The Vice President will lead the integration, modernization, and operational strategy of enterprise telephony and contact center platforms. They will collaborate with stakeholders to implement scalable, AI-driven solutions that enhance customer experience and operational efficiency across healthcare lines of business.
The Care Navigator assesses member needs to develop and coordinate personalized care plans while providing education and support to members and their families. They also facilitate access to community resources and collaborate with healthcare providers to ensure high-quality, cost-effective care outcomes.
The officer will translate privacy, security, and AI requirements into actionable enterprise controls while building relationships with health plan leadership. They are responsible for managing compliance evidence, audit readiness, and overseeing the accuracy of documentation across the organization.
The Quality Practice Advisor establishes relationships with physician practices to educate them on HEDIS measures, risk adjustment, and documentation standards. They also analyze performance data to identify improvement opportunities and support quality intervention strategies.
The Vice President will oversee the product development function, formulating vision and strategy for clinical technology portfolios while driving the deployment of AI-enabled capabilities. They will manage enterprise-wide roadmap priorities, vendor accountability, and ROI measurement to ensure scalable and compliant automation across clinical workflows.
The Medical Director assists in directing medical management, quality improvement, and credentialing functions while providing leadership for utilization management and cost containment. They also collaborate with clinical teams to optimize outcomes for high-risk patients and ensure compliance with regulatory and accreditation standards.
The Senior Care Manager assesses, plans, and implements complex care management activities to ensure high-quality, cost-effective healthcare outcomes for members. They also collaborate with providers and caregivers to develop personalized care plans while providing guidance and coaching to clinical new hires.
Develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. Coordinates with providers and families to address unmet needs, monitor progress, and update personalized care plans.
Develops and maintains the organization's contract governance and vendor management oversight framework while conducting risk-based audits to ensure regulatory compliance. Provides leadership to a team of professionals and serves as a primary point of contact for vendor relationship managers regarding oversight requirements.
The LTSS Service Care Manager develops and coordinates holistic care plans to ensure quality, cost-effective healthcare outcomes for long-term care members. They also conduct site visits, educate families on available services, and maintain documentation to ensure compliance with regulatory standards.
The Care Navigator develops and coordinates personalized care plans to improve healthcare access and outcomes for members. They provide psychosocial support and facilitate access to community resources while maintaining compliance with regulatory standards.
The Business Process Consultant leads large-scale, cross-functional initiatives focused on regulatory compliance, encounter quality, and operational process improvement. They are responsible for facilitating performance optimization, designing future business solutions, and driving consensus across multiple markets.
Develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. Collaborates with providers and families to create personalized care plans and address social determinants of health.
The Sales Representative will develop market penetration for Medicare products by conducting community outreach, home visits, and personalized appointments to facilitate enrollment. They are responsible for educating prospective members on benefits, assisting with eligibility, and maintaining compliance with regulatory marketing guidelines.
The specialist participates in the oversight of corporate ethics and compliance programs, conducting focused reviews and audits to ensure adherence to contractual and regulatory requirements. They collaborate with business owners and delegated subcontractors to drive remediation and assess compliance risks across various health care programs.
Develops and coordinates personalized care plans to improve healthcare outcomes and access for members. Facilitates access to community resources and collaborates with healthcare providers to ensure timely and high-quality care.
Independently conduct comprehensive reviews of MS-DRG and APR-DRG coding and clinical documentation to ensure accuracy and compliance. Collaborate with the Medical Director on complex cases and contribute to strategic audit initiatives.
The Quality Practice Advisor fosters relationships with physician practices to educate them on HEDIS measures, risk adjustment, and documentation standards. They also analyze performance data to identify improvement opportunities and support quality intervention strategies.
The Senior Compliance Analyst partners with leadership to maintain D-SNP program compliance through regulatory interpretation, reporting, and auditing. They also serve as a liaison for regulatory agencies and lead special projects to ensure adherence to state and federal requirements.
The Care Manager develops, assesses, and facilitates complex care management activities for members with mental and behavioral health needs. They coordinate care plans, collaborate with providers, and provide education to members and their families to ensure high-quality, cost-effective healthcare outcomes.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to engage members and discuss care plans. They coordinate services with healthcare providers and community partners to ensure continuity of care and member satisfaction.
The Care Coordinator II is responsible for managing patient care plans and coordinating services to ensure optimal health outcomes. They will act as a primary point of contact for patients, providers, and families to facilitate effective communication and resource navigation.
Provide national expertise and thought leadership regarding foster care treatment, service needs, and evidence-based practices. Lead the development of mental health assessment toolkits and facilitate training for clinicians across the national network.
Oversee provider contracting, network development, and provider relations functions to ensure organizational efficiency and regulatory compliance. Perform complex financial analyses to identify cost improvement opportunities and execute strategies for new and existing market expansions.
The Medical Director assists in coordinating medical management, quality improvement, and credentialing functions while providing clinical leadership for utilization management and cost containment. They also collaborate with clinical teams and providers to optimize patient outcomes and ensure compliance with regulatory and accreditation standards.
Develops, assesses, and facilitates complex care management activities for members with mental and behavioral health needs. Coordinates care plans between members, families, and providers to ensure accessible, high-quality healthcare outcomes.
Develops, assesses, and facilitates complex care management activities for members with mental and behavioral health needs. Coordinates care plans between members, families, and providers to ensure high-quality, cost-effective healthcare outcomes.
Leads the strategic direction and development of SIU capabilities to detect and prevent fraud, waste, and abuse within healthcare programs. Manages analytics personnel and collaborates with cross-functional stakeholders to drive data-informed strategies and actionable intelligence.
The Quality Improvement Coordinator II conducts compliance reviews of delegated entities, performs medical record audits, and investigates quality of care complaints. They also act as a liaison between community resources and the company while developing corrective action plans and reporting on clinical initiatives.
Develops and coordinates personalized care plans to improve healthcare outcomes for members. Provides psychosocial support and connects members with necessary community resources and healthcare providers.
The Senior Director of Pharmacy manages pharmacy operations, develops benefit management programs, and establishes strategic vision across multiple markets and products. They are responsible for overseeing pharmacy utilization, contract administration, budget planning, and leading pharmacy department staff.
The Vice President of Finance provides leadership and proactive management for all FP&A and G&A activities, including developing the Annual Operating Plan and monitoring financial performance. They are responsible for identifying medical cost trends, overseeing pricing models, and providing strategic financial guidance to senior management.
The Senior Director will oversee the Gold Card Program, ensuring effective performance and communication of strategic priorities to stakeholders. They will lead long-term program development initiatives and ensure the integration of adaptive technology and expert team-based services across business units.
The Lead IAM Engineer will design, build, and maintain scalable identity and access management solutions while leading cross-functional teams through implementation processes. They are responsible for enforcing identity lifecycle management policies and troubleshooting complex security-focused IAM issues.
Supervise and coordinate the daily activities of the Coding & Clinical Review team to ensure accurate DRG assignment, clinical validation, and audit outcomes. Monitor team performance, provide guidance on complex coding matters, and ensure compliance with regulatory and organizational standards.
The Medical Director assists in directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. They provide medical leadership for utilization management, cost containment, and collaborate with clinical teams to optimize outcomes for high-risk patients.
The Medical Director assists in directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. They provide medical leadership for utilization management, cost containment, and collaborate with clinical teams to optimize patient outcomes.
Lead the transformation of business strategy by designing solutions and estimating value realization for organizational initiatives. Partner with senior leadership to create business architecture models and maintain governance across delivery groups.
Executes the enterprise-wide Incident Response Plan and implements security service audit schedules to identify shortfalls. Collaborates with security architects and engineers to integrate third-party threat reporting into internal CIRT systems.
Direct and coordinate medical management, quality improvement, and credentialing functions to optimize member care and cost-effectiveness. Perform medical reviews of complex cases and provide leadership for utilization management and regulatory compliance.
Direct and coordinate medical management, quality improvement, and credentialing functions to optimize care for members. Provide medical leadership for utilization review and cost containment while collaborating with clinical teams and providers.
Develops and facilitates complex care management plans for members with mental and behavioral health needs. Coordinates between members, families, and providers to ensure access to cost-effective healthcare and community resources.
Directs long-term care management for members with physical and behavioral health needs to ensure high-quality, cost-effective outcomes. Leads the design, implementation, and growth of LTSS programs while overseeing staff caseloads and regulatory compliance.
Translates privacy, security, and AI requirements from contracts and laws into actionable enterprise controls. Builds relationships with leadership to ensure compliance reporting, audit readiness, and continuous improvement across health plans.
The role involves managing the corrections process by triaging non-compliance issues and coordinating remediation efforts using GRC tools. It requires collaborating with stakeholders to develop corrective action plans and providing trend analysis for senior leadership.
Investigate allegations of healthcare fraud, waste, and abuse through claims audits and data analysis. Prepare detailed investigative reports for referral to state and federal agencies.
Accountable for the Medical Loss Ratio (MLR) compliance and reporting program, ensuring accurate calculations and timely federal and state filings. Leads cross-functional alignment and provides strategic oversight of MLR methodology, governance, and regulatory examinations.
Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, cost recovery, and payment accuracy. Manage a team of auditors and clinical professionals to ensure compliant determinations and alignment with regulatory requirements.
Direct provider network strategy and contracting activities, including access analysis and reimbursement management. Lead the development of provider networks across expansion markets and oversee budgeting and forecasting for network costs.
The Utilization Review Clinician performs reviews of members' care and health status related to Applied Behavioral Analysis (ABA) services to determine medical appropriateness. They monitor clinical effectiveness and efficiency of care in accordance with ABA guidelines and provide education to members and their families regarding the utilization process.
Directs the organization with critical information for fact-based decisions and manages business and reporting analysts to produce operational reports. Leads the execution of projects based on predictive analytics and collaborates with various teams to provide effective reporting solutions.
Identify market trends and oversee functions of quality improvement programs. Collaborate with stakeholders to analyze business issues and recommend solutions for performance improvements.
Develop and facilitate complex care management activities for members, focusing on physical and mental health needs. Collaborate with providers and community resources to create personalized care plans and ensure members receive appropriate care.
The Utilization Review Clinician performs clinical reviews and assesses care related to mental health and substance abuse. They monitor and determine the appropriateness of care levels and services, ensuring they meet medical guidelines.
The Care Coordinator II supports care management activities and ensures services are delivered by healthcare providers. They interact with members through outreach and coordinate care activities based on care plans.
Supports care management activities and ensures services are delivered by healthcare providers. Engages members through outreach to discuss care plans and coordinates care activities as needed.
The Trainer I is responsible for developing and conducting training programs for Member and Provider Service roles in Centene’s contact centers. This includes conducting training needs analyses, evaluating training effectiveness, and assisting in auditing staff work.
The RN Clinical Review Nurse performs concurrent reviews to evaluate the necessity and appropriateness of care being delivered to members. This includes collaborating with healthcare providers and contributing to discharge planning according to established guidelines.
Supports administrative care management activities including outreach, answering calls, and scheduling services. Acts as a point of contact for members and providers to resolve issues and document member records.
Perform day-to-day functions to maintain provider databases and create reports to monitor network compliance with state requirements. Provide general administrative support of the assigned department.
Design and implement instructional strategies that support learning and performance for providers, caregivers, and external stakeholders. Oversee maintenance of training resources and support sites while developing instruments to assess individual change in knowledge and skills.
