Jobs at CareSource

Provide behavioral health utilization management, clinical oversight, and quality improvement for members. Develop and implement evidence-based policies, support regulatory/accreditation activities, consult with providers and state agencies, participate in fraud/quality investigations, and provide training and clinical support to staff and markets.

Serve as servant leader and coach for Scrum teams and the organization to adopt Agile/Scrum; facilitate ceremonies, remove impediments, track metrics, support Product Owner, improve processes, and manage stakeholder relationships to deliver projects.

Lead enterprise clinical data governance and integration: build/maintain clinical data inventory, standardize acquisition requirements, prioritize ingestion and interoperability (FHIR/HL7), oversee data quality and vendor performance, drive use cases from concept to deployment, partner with IT/Data Engineering, and manage a team of analysts to support governance and analytics roadmaps.

Lead actuarial team activities including pricing, forecasting, reserving, and model development. Produce strategic recommendations, manage actuarial processes and vendor work, support rate filings and regulatory interactions, oversee IBNR reserve estimates, and communicate results to leadership.

Provide analytical support and lead claims-related projects: manage IT tickets, analyze claims data, resolve provider claim escalations, develop policies/job aides, assist training, report on OnBase and Facets, and support research and resolution activities for provider inquiries.

Serve as primary member contact during transition to a CCA/CareSource health plan: conduct telephonic outreach, document current and requested services, coordinate with internal and external providers, schedule nurse intake visits, educate members on plan benefits, use motivational interviewing to engage members, and utilize EMR/care management and telehealth technologies to deliver clinical care and coordinate services.

Serve as primary member contact during transition to the health plan via outbound/inbound calls. Document current and requested services, coordinate with internal and external providers, schedule nurse intake visits, educate members on plan offerings, use motivational interviewing to engage members, leverage EMR/claims/pharmacy data, and provide telehealth-based clinical care when appropriate.

Lead and facilitate quality improvement initiatives focused on HEDIS and managed care outcomes. Perform process and gap analyses, manage improvement teams, document and implement PDSA cycles, measure outcomes, analyze survey and vendor data, prepare reports, train staff on improvement tools, and support compliance with federal/state regulations and accreditation standards.

Lead provider contracting, recruitment, engagement, and performance initiatives for an assigned market. Negotiate contracts, analyze financial and quality data, support value-based reimbursement and practice transformation, coordinate with analytics and population health, mentor new hires, and ensure regulatory and accreditation compliance while managing heavy territory travel.

Lead provider contracting, recruitment, and engagement for an assigned market. Negotiate and manage hospital, physician, ancillary, and behavioral health contracts; analyze financial and performance data; support value-based reimbursement and population health initiatives; coordinate credentialing/loading; mentor staff; ensure regulatory compliance and participate in joint operating committees to drive provider performance and satisfaction.

The Claims Management Analyst III leads eBusiness initiatives, manages EDI trading partners, ensures compliance, and analyzes performance for continuous improvement.

The Revenue Cycle Coordinator III ensures timely resolution of member complaints related to eligibility and billing, leads teams, and develops training for compliance with regulatory standards.

The Configuration Architect oversees the architecture for clinical system configurations, ensures alignment with business needs, evaluates solutions, and leads teams in implementing standards and guidelines while mentoring others in the department.

The Senior Manager, DSNP Product Operations leads operational aspects of DSNP products, ensuring compliance, scalability, and efficiency through collaboration and performance oversight.

Lead capacity planning, forecasting, and reporting for multi-site call centers. Develop staffing strategy and budgets, ensure accurate regulatory reporting, implement agent scorecards and speech analytics, drive Lean/Six Sigma continuous improvement, partner with WFM, engineering, finance, and talent acquisition to optimize staffing and operational performance.

The Provider Engagement Specialist oversees performance of delegated partnerships, manages data reports, collaborates with providers to enhance performance, and ensures regulatory compliance.

Senior business analyst leading cross-functional teams to elicit and manage complex requirements, maintain Epics/Features lifecycle, align solutions to strategy, mentor analysts, drive process improvements, and present KPI-driven insights to stakeholders and executive leadership.

Analyze healthcare claims and develop provider reimbursement models using SQL, Python, BI tools, and AI-enabled automation. Perform contract repricing, benchmarking, scenario modeling, and anomaly detection to support contracting, finance, and operations. Collaborate with actuarial, data engineering, clinical, and configuration teams to validate data, implement reimbursement logic, and deliver actionable insights for cost containment and rate development.

Provide high-level administrative support to executives: prepare presentations and reports, manage calendars and travel, handle correspondence, compile data, take meeting minutes, and maintain records. Support special projects and ensure confidentiality and professional office operations.

The DSNP Account Manager builds relationships with providers, resolves issues, and drives program success while collaborating across teams to improve member and provider experiences.