Jobs at CareSource

Manages small-complexity projects from initiation through closure, maintaining schedules, budgets, resources, risks, issues, documentation, governance, and stakeholder communications. Coordinates business and IT resources, tracks milestones and metrics, facilitates meetings, reports status, supports mitigation planning, and ensures adherence to EPMO processes. The role also contributes to project management process improvement and may lead project teams of up to five members.

Leads enterprise AI strategy, architecture, development, deployment, governance, and operationalization across machine learning, NLP, Generative AI, Agentic AI, and RAG initiatives. Develops predictive models and advanced analytics using healthcare data, establishes evaluation and monitoring standards, ensures responsible AI and regulatory compliance, mentors scientific teams, and advises senior leadership. Requires extensive healthcare data science experience, cloud and modern data stack expertise, and leadership of production NLP and Generative AI solutions.

Leads enterprise technology architecture, governance, design validation, roadmaps, lifecycle management, vendor assessments, and IT due diligence. Partners across technology teams to establish architecture strategy and standards while improving cost, availability, security, client experience, and flexibility. Requires substantial IT experience, architecture or technical leadership background, AI security expertise, full-stack development experience, and fluency in Python and server-side JavaScript or TypeScript.

Investigates complex healthcare fraud, waste, and abuse allegations involving providers, facilities, and members. Analyzes claims, eligibility, pharmacy, and clinical data; conducts audits, interviews, medical record reviews, and corrective actions; interprets Medicaid, Medicare, ACA, coding, and billing requirements; coordinates with legal, regulatory, law enforcement, and analytics partners; oversees investigative quality and case outcomes. Requires Arkansas residency, healthcare fraud investigation experience, and AHFI or CFE certification.

Business Analyst III leads requirements elicitation, documentation, modeling, traceability, and process improvement for complex technology projects. The role collaborates with stakeholders, product owners, IT teams, and project managers; maintains features in Azure DevOps; analyzes metrics; supports delivery milestones; resolves escalated issues; and presents recommendations to leadership. It also mentors junior analysts and helps align business needs with technology solutions.

Leads health plan enrollment operations, managing staff, enrollment and financial reconciliation, eligibility file processing, audits, regulatory compliance, enrollment technology, and process improvement. Oversees Facets and 834/DTRR activities, coordinates with vendors and IT, analyzes performance data, manages risk and corrective actions, and develops team members. Requires knowledge of Medicaid, Medicare, Dual coverage, HIPAA enrollment transactions, and health plan regulatory requirements.

Analyzes healthcare encounter and claims data, resolves data and process issues, supports CMS and state regulatory submissions, monitors SLAs and performance metrics, and contributes to testing, reporting, automation, and process improvement. The role collaborates with IT, claims, enrollment, vendors, and regulatory stakeholders while ensuring compliant encounter reconciliation and accurate claims data.

Provides high-level administrative support to a Finance executive and assigned organization. Responsibilities include preparing presentations, spreadsheets, reports, correspondence, and meeting materials; managing calendars, meetings, records, travel, expense reports, and communications; conducting research; recording meeting minutes; and handling confidential information. Requires strong organizational, communication, problem-solving, multitasking, typing, and Microsoft Office skills in a professional office environment.

Provides community-based nursing case management for dual-eligible members with complex medical, behavioral, and social needs. Conducts assessments, develops and updates care plans, leads interdisciplinary teams, coordinates providers and community resources, supports transitions after hospitalization, educates members on benefits and chronic-condition management, and advocates for member needs. The role requires regular mobile travel throughout Massachusetts, often exceeding 50% of work time.

Develop and deploy AI-enabled applications, web interfaces, and workflow integrations using low-code platforms and modern programming frameworks. Build Python and SQL automation, integrate generative AI and NLP capabilities, collaborate with data and business teams, and support testing, troubleshooting, Agile delivery, deployment, and incident management. Ensure solutions meet usability, accessibility, compliance, and performance standards.

Leads advanced data science and machine learning initiatives for healthcare payment integrity, including fraud, waste, and abuse detection, anomaly identification, predictive modeling, statistical analysis, dashboards, and recovery investigations. Provides technical leadership, mentors analysts, integrates production analytical solutions, collaborates with legal and business stakeholders, and presents findings to leadership. Requires healthcare expertise, advanced SQL and programming skills, and knowledge of claims, billing, reimbursement, and program integrity.

Provides analytical support for healthcare claims payment policies, clinical edits, reimbursement analysis, regulatory updates, configuration changes, UAT, and post-production validation. Researches payment discrepancies, identifies root causes, documents policy decisions, monitors claims processing accuracy, and communicates findings to providers and internal stakeholders. Requires health plan or provider coding and payment policy experience, strong knowledge of healthcare coding systems, claims operations, managed care, Medicare, Medicaid, and CMS guidelines.

Manages relationships with LTSS and HCBS providers across Ohio, focusing on provider satisfaction, retention, onboarding, education, billing support, regulatory changes, and Electronic Visit Verification compliance. Serves as a subject matter expert and liaison among providers, care management, operations, and leadership. Produces reports and business documents, supports network strategy and implementation, resolves provider issues, and leads internal and external stakeholder meetings. Requires extensive regional travel.

Leads enterprise enrollment operations across healthcare product lines, overseeing enrollment lifecycle activities, system integrations, data integrity, reconciliations, vendors, regulatory compliance, audits, and process transformation. Partners with IT and external agencies, manages CMS and Medicaid transactions, establishes operational controls and reporting frameworks, and develops high-performing teams. Requires extensive leadership experience and expertise in Medicaid managed care, Medicare Advantage, or Dual Special Needs Plans.

Provides financial leadership for a market or region through reporting, budgeting, forecasting, business reviews, reimbursement and pricing analysis, regulatory filings, audits, risk assessment, internal controls, and quality improvement initiatives. Partners with executives, regulators, actuaries, providers, and market leaders while managing finance staff and supporting growth, revenue maximization, and strategic decision-making.

Leads ElderServe Health’s legal, compliance, regulatory, governance, and risk functions. Advises executive leadership, oversees legal and regulatory strategy, ensures compliance with healthcare laws and government program requirements, manages significant transactions and partnerships, represents the organization with regulators and stakeholders, and develops departmental capabilities, budgets, talent, and performance measures.

Promotes CareSource health insurance products through community outreach, educational presentations, enrollment events, and relationship management. Builds partnerships with community organizations, agencies, providers, government groups, and targeted industries to drive membership acquisition and retention. Maintains territory plans, CRM records, reports, regulatory compliance, and marketing budgets. The role requires regular travel, potentially exceeding 50%, throughout the assigned North Georgia territory.

Develop complex healthcare reports, ETL solutions, databases, and Power BI dashboards for LTSS and Dual Eligible programs. Analyze multidimensional data, ensure governance and accuracy, identify operational improvements, and deliver actionable insights to leadership. The role translates business requirements into scalable reporting solutions, collaborates with clinical, operational, data engineering, and IT teams, and leads testing, process automation, visualization, and large cross-functional data projects.

Leads hospital and provider value-based payment programs within Nevada, overseeing contract implementation, quality metrics, financial targets, provider engagement, reporting, compliance, and corrective action plans. Collaborates with health plans, hospitals, providers, and internal stakeholders to improve care quality, utilization, member experience, and incentive performance. Manages strategic provider performance initiatives, analyzes data, participates in committees, and supports Medicaid managed care objectives.

Leads enterprise business analysis strategy across multiple programs and portfolios. Partners with executives on business cases, investment decisions, requirements, prioritization, risks, value realization, and transformation initiatives. Establishes governance, methodologies, standards, and performance measures while guiding complex requirements efforts. Analyzes operational and financial data, supports payer regulatory compliance, drives AI and automation adoption, and mentors business analysts and project teams.