The Program Specialist II oversees the implementation of assigned programs and leads initiatives to improve service delivery and outcomes for specific populations. They are responsible for developing work plans, analyzing outcome data, and representing the company in community and state meetings.
The Care Coordinator II 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 document member records according to regulatory standards.
The Clinical Appeals Coordinator acts as a liaison for statewide appeals and fair hearings while ensuring all documentation complies with State and NCQA standards. They review clinical information to determine medical necessity and coordinate with Medical Directors to clarify clinical rationales.
Analyze integrated healthcare datasets to extract insights that influence business decisions and reduce the cost of care. Collaborate with stakeholders to develop solutions, automate processes, and communicate data-driven recommendations.
The role involves performing administrative care management activities, including conducting outreach and scheduling services for members. You will serve as a primary point of contact to resolve inquiries and maintain accurate non-clinical member records.
Lead operational strategy and process improvements across shared services, translating business objectives into scalable operating plans, procedures, and capabilities. Coordinate product, market, and corporate stakeholders; monitor performance and risks; and support product expansion, integration, and operational readiness.
Analyze contact center workload, forecasts, staffing patterns, and performance metrics to develop efficient schedules and data-driven staffing recommendations. Maintain staffing records, prepare scheduled and ad-hoc reports, assess staff productivity, and support workforce management policies and procedures.
Review prior authorization requests to assess medical necessity, clinical appropriateness, and level of care, escalating cases to Medical Directors when appropriate. Coordinate with providers and internal teams, document clinical information, support transfer and discharge planning, and help improve authorization processes and care quality.
Analyze and report operational and governance data, maintain dashboards, reports, trackers, and process documentation, and support data quality and process improvement initiatives. Prepare summaries and materials for leadership and governance meetings while collaborating across teams on PCP assignment and attribution processes.
Lead organization-wide process excellence initiatives using Six Sigma and Lean methods to identify and address operational inefficiencies. Oversee business and program implementations, coordinate cross-functional teams, communicate project status, and mentor team members and stakeholders.
The Senior Manager will lead the development of network performance analytics and oversee the financial impact analysis of contract negotiations and rate changes. They will also collaborate interdepartmentally to provide analytic support and training on network performance applications.
The Claims Analyst is responsible for the timely processing of medical claims and verifying information for reimbursement eligibility. They must maintain accurate records and ensure all payments or denials comply with company protocols and quality standards.
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 monitor member progress while ensuring compliance with regulatory standards.
The Director of Vendor Management oversees vendor relationships to ensure compliance with performance metrics and regulatory standards. They facilitate communication between vendors and internal partners while managing performance improvement plans and conducting oversight audits.
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 healthcare outcomes.
The care manager develops and coordinates holistic care plans for members with significant mental or behavioral health needs. They act as a liaison between members, families, and providers while performing regular site visits to ensure quality and cost-effective outcomes.
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 Project Manager II plans, organizes, and oversees cross-functional projects to meet strategic objectives throughout the full project life cycle. They are responsible for managing budgets, resources, and project documentation while ensuring deliverables meet quality standards.
The Service Care Manager develops and coordinates holistic care plans for members with significant mental and behavioral health needs. This role involves frequent field visits, member advocacy, and facilitating access to community resources and medical services.
Analyze integrated healthcare datasets to identify cost-saving opportunities and improve clinical outcomes for members. Lead large-scale projects and translate complex business goals into actionable data-driven solutions.
The role involves supporting administrative care management activities, including member outreach, scheduling services, and resolving inquiries. It also requires maintaining non-clinical member records and connecting members to community resources to ensure high-quality care.
The Data Analyst III is responsible for managing complex data projects and providing advanced analytical support across various healthcare domains. They will extract, model, and reconcile large datasets while mentoring other analysts and ensuring compliance with reporting requirements.
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 HR Program Manager III will lead and oversee multiple concurrent projects for the executive coaching program to improve efficiency and service levels. They are responsible for managing the full project lifecycle, including resource allocation, budget management, and stakeholder communication.
The Senior Quality Improvement Specialist coordinates regulatory, accreditation, and clinical quality initiatives while managing complex projects to improve healthcare outcomes. They also conduct vendor oversight, develop performance improvement programs, and collaborate with cross-functional teams to ensure compliance with industry standards.
The manager oversees daily operations of a specialty pharmacy call center, including staffing, performance metrics, and technology implementation. They also coordinate with cross-functional teams to resolve complex patient and provider escalations while ensuring compliance with regulatory standards.
Contribute to projects across cybersecurity and related security functions, applying academic knowledge while developing technical and analytical skills. Communicate project progress and results, collaborate with security professionals, and participate in training and development activities.
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 unmet needs and monitor member progress toward health goals.
The Director of Clinical Program Design oversees the research, development, and implementation of clinical programs to ensure compliance with state, federal, and HEDIS requirements. They lead cross-functional teams and collaborate with leadership to design strategies that align with organizational goals and resource allocation.
The Senior LTSS Service Care Manager assesses and coordinates medical and support services for high-acuity members to ensure quality, cost-effective care. They develop personalized care plans, educate families, and collaborate with healthcare providers to monitor member progress and facilitate necessary treatments.
The coordinator develops and manages holistic care plans for long-term care members while educating families on available services and benefits. They also monitor member outcomes and collaborate with healthcare providers to ensure accessible and cost-effective care.
The Data Analyst III is responsible for managing complex data projects and providing advanced analytical support for various business operations including claims, provider, and clinical data. They will extract, model, and reconcile large datasets while mentoring other analysts and reporting findings to management.
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 ERM Analyst identifies, assesses, and reports on complex enterprise-wide risks while supporting corporate sustainability and ESG initiatives. They collaborate with business units to gather data, track performance metrics, and implement risk management strategies.
The developer will plan, configure, and build technological solutions to address business challenges while conducting research and requirement gathering. They will also act as a subject matter expert, mentor colleagues, and lead meetings to ensure effective product development.
Performs clinical reviews to assess the medical appropriateness of mental health and substance abuse services. Engages with providers, members, and leadership to improve care quality, efficiency, and discharge planning.
The Claims Analyst II is responsible for processing complex medical claims, verifying information, and determining reimbursement eligibility based on policy and contract provisions. They also resolve adjustments, appeals, and provider inquiries while maintaining department production and quality standards.
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 education regarding disease processes and benefit options.
Assess members’ behavioral health and social needs, develop personalized care plans, and coordinate access to providers, specialists, and community resources. Monitor member status and care outcomes, document activities for regulatory compliance, and educate members and families about treatment, referrals, and healthcare benefits.
Assess post-discharge members’ health, medication, and support needs, then develop and coordinate care plans and transition services with providers, caregivers, and interdisciplinary teams. Provide education and outreach, document care activities in compliance with regulations, and identify opportunities to improve care quality and cost effectiveness.
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 and effective healthcare outcomes.
The nurse performs concurrent reviews to evaluate medical necessity, acuity levels, and the overall health of members receiving inpatient care. They also collaborate with medical directors and healthcare providers to facilitate effective discharge planning and ensure compliance with utilization management policies.
The Finance Analyst II will compile and analyze financial information, including revenue and expense projections, reports, and presentations. They are responsible for performing financial forecasting, reconciling internal accounts, and identifying trends to present to senior management.
Lead sales operations functions including data management, systems oversight, and broker support while aligning with finance on sales projections. Oversee the sales operations department and guide sales leadership on goal setting, process implementation, and complex cross-functional projects.
The Care Navigator develops and coordinates personalized care plans for foster care members to improve health outcomes and access to services. They provide ongoing support, monitor member progress, and collaborate with healthcare providers and caregivers to ensure needs are met.
The analyst supports merger and acquisition activities by conducting financial modeling, valuation analysis, and due diligence. They also monitor industry trends and prepare summary materials for Board-level review.
Designs, develops, validates, and supports complex data solutions, databases, reports, applications, and automations for claims audit sampling and analytics. Leads technical initiatives, resolves production issues, ensures data accuracy and control compliance, and partners with business, technology, risk, and vendor teams.
Develop Medicare product sales and enrollment in the assigned territory through community outreach, events, home visits, and personalized appointments. Educate and assist members with enrollment, recertification, healthcare access, and related services while following marketing regulations and reporting on territory activity.
The Lead VBC Quality Consultant serves as a strategic advisor for Value-Based Care organizations, analyzing performance data to improve quality outcomes like Medicare Stars and HEDIS. They act as the primary liaison between internal teams and external providers to coordinate quality initiatives and monitor performance against contractual goals.
The supervisor manages the care management team and oversees behavioral health care coordination to ensure quality service delivery. They are responsible for monitoring compliance, assigning caseloads, and providing coaching and guidance to staff and providers.
Leads the enterprise AI innovation and strategic technology partnerships function to drive high-value AI use cases and technical strategies. Collaborates with cross-functional leaders to integrate AI solutions, manage vendor platforms, and ensure alignment with enterprise architecture and governance standards.
The analyst supports enterprise HEDIS quality oversight, audit readiness, and submission execution activities. They collaborate with cross-functional partners to ensure documentation and deliverables meet regulatory standards.
The Quality Practice Advisor fosters relationships with physician practices to educate them on HEDIS measures, documentation, and coding standards. They also support the development and implementation of quality improvement interventions and audits to ensure plan compliance.
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 to review complex cases and medical necessity appeals while ensuring compliance with regulatory and accreditation standards.
Assess members’ healthcare needs and barriers, develop personalized care plans, and coordinate access to providers, specialists, and community resources. Educate and support pregnant members and their families, monitor care-plan progress, document activities, and collaborate with care teams to address changing needs.
The Care Navigator assesses member needs and coordinates personalized care plans to improve healthcare outcomes and access. They provide psychosocial support and facilitate connections to community resources such as housing, employment, and education for foster care members.
Conduct comprehensive reviews of medical records and billing documentation to identify potential fraud, waste, and abuse. Collaborate with internal teams to validate services against regulatory guidelines and provide investigative support for billing issues.
The Pharmacy Provider Liaison acts as a bridge between providers and the health plan to resolve injectable claims issues and provide training on pharmacy policies. They conduct regular on-site meetings with providers to document issues, assist with case management, and ensure successful outcomes for members.
Develops and facilitates complex care management activities, including personalized care plans and education for members and their families. Coordinates with providers and community resources to address unmet needs and monitors member progress toward care goals.
The Care Manager develops and facilitates complex care management activities for members with mental and behavioral health needs, including personalized care plans and education. They coordinate services between members, families, and providers while monitoring clinical outcomes and ensuring regulatory compliance.
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 unmet needs and monitor member progress toward health goals.
The HEDIS Specialist will supervise and facilitate interventions to improve behavioral health HEDIS and Pay for Performance measures. They will partner with clinical leadership to analyze data, implement quality improvement strategies, and report on the financial impact of these initiatives.
The role is responsible for building and governing the enterprise knowledge foundation to power AI-generated insights and agentic production. It involves leading knowledge strategy, data governance, and cross-functional collaboration to ensure information assets are accurate, discoverable, and aligned with business goals.
The Chief Operating Officer is responsible for the day-to-day operations, profitability, and growth of the business unit. They will develop strategic plans, manage provider and stakeholder relationships, and ensure compliance with state and federal regulatory requirements.
The Care Navigator develops and coordinates personalized care plans to improve healthcare outcomes and access for members. They provide psychosocial support and facilitate connections to community resources while ensuring compliance with regulatory standards.
The manager will oversee claims analysis and research to identify process improvements and root causes of operational issues. They are responsible for mentoring business analysts and implementing solutions to ensure claims operations meet performance targets.
Interns will learn about various processes within the Managed Care industry by contributing to projects that support business objectives. They are responsible for researching legal and regulatory topics and communicating project status to mentors and management.
Leads and directs long-term care management strategies to improve healthcare outcomes and member experience. Oversees departmental operations, including staff caseloads, policy enforcement, and budget monitoring to ensure compliance with state and federal regulations.
The Vice President oversees provider network strategy, contracting negotiations, and unit cost management to support company growth and expansion. They are responsible for establishing the department's strategic vision, managing budgets, and leading due diligence for M&A activities.
The consultant is responsible for clinical content in data collection, account implementations, and audit activities to ensure high-quality tracking and performance. They lead data analysis projects, document business processes, and support regulatory compliance reporting for clinical service teams.
The manager oversees the design, management, and strategy of cloud systems while leading a team responsible for platform engineering and operational excellence. They partner with architecture and security teams to enforce standards and ensure the reliability and performance of cloud infrastructure.
The psychologist will authorize, direct, and monitor behavioral health and substance abuse care based on clinical information and medical necessity. They will also conduct peer reviews, provide education to network practitioners, and facilitate outpatient clinical rounds.
The Lead Business Solutions Developer strategizes, plans, and builds complex technical solutions to address business challenges. They lead project teams, conduct requirements gathering, and mentor peers while ensuring scalable product development.
The Care Manager develops and facilitates complex care management activities, including personalized care plans and education for Medicaid members. They coordinate between members, families, and providers to ensure access to appropriate care while monitoring progress toward health goals.
The Care Manager develops and facilitates complex care management activities, including personalized care plans and education for members and their families. They also coordinate between members, caregivers, and providers to ensure access to necessary services while maintaining compliance with regulatory standards.
The Care Manager develops and facilitates complex care management activities, including personalized care plans and education for members and their families. They also monitor member status and collaborate with providers to ensure timely access to necessary healthcare services.
The Care Manager develops and facilitates complex care management activities, including personalized care plans and education for members and their families. They also coordinate care between members, caregivers, and providers while monitoring progress and ensuring compliance with regulatory requirements.
The Senior Manager oversees a team of engineers responsible for designing and implementing complex enterprise software solutions while managing project scope, schedule, and budget. They also lead staff development, vendor management, and ensure compliance with security and change management policies.
The Senior Curriculum Designer will design, implement, and maintain training resources while leading stakeholder meetings to align learning strategies with business requirements. They are responsible for creating virtual simulations, assessments, and training project plans to support operational goals and quality results.
The role involves designing, developing, and implementing enterprise software solutions while collaborating with cross-functional teams. It also requires monitoring critical production processes, troubleshooting issues, and implementing process improvements for scalability and data quality.
Oversee the development and implementation of hospital provider contracting activities and network enhancement strategies. Direct negotiations with complex hospital systems while monitoring performance and quality gaps to meet organizational objectives.
The Care Navigator assesses member needs to develop and coordinate personalized care plans while providing advocacy and education 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 Lead Clinical Appeals Coordinator acts as a liaison for statewide appeals and ensures all appeal letters comply with State and NCQA requirements. The role involves reviewing clinical information to determine medical necessity and coordinating with Medical Directors to clarify clinical rationale.
The Business Solutions Developer III designs, develops, and implements business-managed applications, automations, and data solutions to address complex operational needs. This role also provides technical guidance to peers, conducts code reviews, and facilitates requirements gathering with stakeholders.
The specialist will manage the end-to-end home modification process, including creating specifications, obtaining quotes, and ensuring compliance with waiver and contract requirements. They will also communicate with vendors, contractors, and care management staff to ensure timely project completion.
Analyze integrated datasets to extract value and influence business decisions while collaborating with stakeholders to reduce the cost of care. Develop and maintain complex scripts and reports while providing technical guidance to junior analysts.
The manager oversees regulatory filings, legislative research, and the maintenance of product benefit databases to ensure compliance and operational quality. They serve as the primary point of contact for state insurance departments and lead cross-functional teams in developing and auditing member-facing materials.
The manager leads a team responsible for facilitating external audits related to risk adjustment processes and ensuring compliance with regulatory requirements. They serve as the primary point of contact for auditors, manage deliverable submissions, and collaborate with internal partners to address identified risks.
The manager will oversee business processes related to risk adjustment and quality improvement across assigned products and plans. They are responsible for developing operational workflows, managing risk adjustment strategies, and preparing performance dashboards for senior management.
The Service Care Manager develops and coordinates holistic care plans to ensure quality, cost-effective healthcare outcomes for long-term care members. They also provide education to members and their families while monitoring care plan status and collaborating with healthcare providers.
The Care Coordinator II supports care management activities by performing member outreach via phone or home visits to discuss care plans and service needs. They coordinate care activities with healthcare providers and community partners to ensure continuity of care and member satisfaction.
The Director of Pharmacy is responsible for the strategic, operational, and regulatory oversight of the pharmacy benefit program for the Indiana health plan. They will manage vendor relationships, implement pharmacy policies, and ensure compliance with state and corporate objectives.
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 the quality and efficiency of care.
Develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for Medicaid members. Collaborates with providers and families to create personalized care plans and monitors progress toward health goals.
The Care Navigator develops, assesses, and coordinates personalized care plans for foster care members to improve healthcare outcomes. They provide psychosocial support and facilitate access to community resources while maintaining compliance with regulatory standards.
The Care Navigator develops and coordinates personalized care plans for foster care members to improve health outcomes and access to services. They also provide psychosocial support and collaborate with families, caregivers, and healthcare providers to ensure timely access to community resources.
The Care Navigator develops and coordinates personalized care plans for foster care members aged 10-21 to improve health outcomes. They also provide psychosocial support and advocate for members to ensure timely access to community resources and healthcare services.
Leads the end-to-end strategy, development, and execution of product and digital experiences for the ICHRA business. Partners with cross-functional teams to translate market insights into scalable solutions that drive growth and operational excellence.
The Quality Practice Advisor fosters relationships with physician practices to educate them on HEDIS measures, documentation, and coding standards. They also collect and analyze performance data to identify opportunities for quality improvement and gap closure.
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 unmet needs while ensuring compliance with regulatory standards.
Develops and facilitates complex care management activities, including personalized care plans and education for members and their families. Coordinates care between members, caregivers, and providers to ensure timely access to services and monitors progress toward health goals.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to ensure continuity of care. They coordinate services based on care plans, communicate with healthcare providers, and maintain accurate member records in compliance with regulatory standards.
The Senior HEDIS Quality & Audit Analyst leads complex audit workstreams and ensures accurate, audit-defensible documentation for NCQA and CMS submissions. This role acts as a subject matter expert to interpret regulatory requirements and drive continuous improvement in quality oversight.
The Sales Representative will develop market penetration for Medicare products by educating individuals and facilitating enrollment through community outreach and personalized appointments. They are responsible for maintaining compliance with regulatory guidelines, conducting home visits, and participating in local events to generate enrollments.
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, manage network performance, and drive improvements in quality and cost utilization.
The intern will support the creation of AI-enabled Power BI dashboards and perform quantitative analysis on healthcare data to support business intelligence. Additionally, they will research regulatory topics and contribute to various projects to develop professional competencies within the Managed Care industry.
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 VP of Network Development & Contracting oversees provider network strategy, including access analysis, contract negotiations, and unit cost management. They are responsible for establishing the department's strategic vision and supporting market expansion and M&A activities through contract analysis.
The supervisor manages a care coordination team to ensure high-quality delivery of long-term care services and compliance with regulatory standards. They are responsible for assigning caseloads, providing staff coaching, and handling complex escalations involving members and providers.
The coordinator assesses member needs to develop and monitor personalized long-term care plans while facilitating access to community resources and healthcare services. They also provide ongoing education to members and their families to ensure quality, cost-effective healthcare outcomes.
The Commercial Product Manager supports the product development life cycle for Ambetter marketplace products to drive growth and retention. Responsibilities include conducting competitive intelligence, market analysis, and ensuring product designs align with regulatory requirements.
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 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 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 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.
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 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 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 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 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.
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 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.
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.
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 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 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.
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.
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.
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.
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.
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 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 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.
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 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 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 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 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.
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.
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.
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 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 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.
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.
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 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 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 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 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 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.
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 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 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 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.
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 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 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 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 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.
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 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 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 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 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 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.
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 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.
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.
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 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 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 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.
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.
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.
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 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.
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.
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 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.
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.
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.
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 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.
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.
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.
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.
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.
