CareSource Jobs

The Operations Specialist III provides analytical support and leadership for key Claims-related projects. Essential Functions: Regulatory reporting such as CMS and Medicaid Prompt Pay Serve as high dollar claims reviewer Identify payment integrity issues with claims reimbursement methodologies Prepare and deliver responses to legal correspondence and state complaints Provide Claims Subject Matter Expertise (SME) for cross-functional meetings including operational and new business implementation Act as primary Claims Representative and SME for corporate projects Act as primary Claims Representative on external audits Assist in development of policies and procedures for claims processing, COB, appeals and adjustment functions Lead Claims initiatives such as working with IT and others to automate claim functions; improve front end paper claim process; and report development with SIS Contribute to and/or develop user stories or provide user story guidance for sprint planning Implement new business including the design, testing and delivery of supporting processes to the business Perform any other job related instructions, as requested Education and Experience: Bachelor's degree or equivalent years of relevant work experience required Minimum of five (5) years of healthcare claims environment, equivalent managed care, healthcare operations or professional industry experience is required Competencies, Knowledge and Skills: Advanced proficiency level experience in Microsoft Word, Excel and PowerPoint Data analysis and trending skills Work with accumulators Demonstrated understanding of claims operations specifically related to managed care Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding Effective communication skills Strategic management skills Ability to work independently and within a team environment Attention to detail Critical listening and thinking skills Negotiation skills/experience Technical writing skills Time management skills Decision making/problem solving skills Licensure and Certification: None Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation Range: $70,800.00 - $113,200.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.#LI-RW1

Exemption Status:United States of America (Exempt)$85,356 - $115,232 - $145,107 “Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.” This position is not eligible for Sponsorship. MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team! Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare. At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution! Job Description The Account Executive is responsible for the success of the overall client business relationship of Complex Accounts, Strategic Key Accounts, and entire assigned book of business. Provides proactive and strategic support for achieving financial goals resulting from successful oversight of client deliverables, renewals and upsell activity. Manages all aspects of business relationships with minimal management involvement and exhibits a track record of performance that exceeds expectations. Ensures customer satisfaction, and effectively leads the account client team focusing on service, revenue, and operational efficiency as identified in strategic plans for the client and MedImpact. This position operates with a very high level of autonomy on complex business issues while requiring minimal management oversight. What You Get To Do: Level I Manage book of business in pursuit of fiscal revenue targets as set by management Develop and manage the account team annual strategic plan for assigned book of business to address all aspects of client lifecycle, including but not limited to service, financial, growth and clinical initiatives based on an understanding of each client's business needs Ensure high degree of client satisfaction and retention through demonstrable results and by effectively leading the service team to achieve client service goals Effectively utilize MedImpact forums and resources to proactively address client needs and to escalate issues where appropriate Provide timely feedback of strategic plan performance and outcomes to the management to ensure service and growth opportunities are maximized and incorporated into the organizational strategy planning process Provide oversight of projects and client initiatives and assists in the interpretation and context of client requests Maintain the integrity of the annual strategic business plan and manage the fiscal revenue plan Manage client renewal process, including participation in development and review of proposal of pricing terms in lieu of the fiscal revenue plan, mitigate organizational risks with respect to performance guarantees, and unveil opportunities for MedImpact product usage as well as client growth and expansion Lead renewal presentations. Utilize all internal pro-forma financial tools and forums to ensure preparedness and success Support the implementation process for assigned clients, including oversight of implementation and contract terms Negotiate and manage client contract throughout the lifecycle of the account Build strong and positive internal relationships with your account service matrix team in order to realize the full potential of the assigned book of business Coordinate with MedImpact subject matter experts to increase knowledge of MedImpact products, services, and industry information to be incorporated into and strengthen client relationship Organize and lead client business planning meetings, quarterly and annual executive pharmacy briefings, client leadership councils and internal team strategy planning discussions Demonstrate proficiency in Excel, Word and PowerPoint, organizational web-based tools in support of these functions Supports and assists in sales and prospect presentations Develops and maintains effective relationships with client consultants as appropriate The Perks: Medical / Dental / Vision / Wellness Programs Paid Time Off / Company Paid Holidays Incentive Compensation 401K with Company match Life and Disability Insurance Tuition Reimbursement Employee Referral Bonus To explore all that MedImpact has to offer, and the greatness you can bring to our teams, please submit your resume to ************************* MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets. Equal Opportunity Employer, Male/Female/Disabilities/VeteransOSHA/ADA: To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Disclaimer: The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

Summary of Job Oversee and actively participate in quality improvement projects. Contribute to the overall success of Quality Programs by promoting advancing the department mission of effectively managing members and improving health outcomes. Serve as the Quality Management liaison for internal and external partners for projects and improvement initiatives. Subject matter knowledge expert with regards to quality improvement & reporting. Responsibilities * Work directly with business partners to plan, implement, and oversee ongoing operational execution of quality improvement projects and action plans (HEDIS, CAPHS, and HOS) to meet corporate business goals for Medicare, Medicaid, QHP, and Commercial product lines. * Support the execution of centrally developed and data-driven strategic plans. * Assist in leading cross-functional teams for collaboration on HEDIS, CAHPS, HOS, Pharmacy, and Enterprise metrics. * Serve as a point of contact for quality vendors: develop and share target lists; provide support in monitoring performance against established Service Level Agreements; provide a communication bridge between the company/line(s) of business and the vendors. * Manage ongoing quality programs including Member Rewards & Incentives, Provider Quality Incentives, and addressing Health Disparity initiatives. * Provide subject matter expertise and support on all quality metrics to key stakeholders. * Support NCQA/CMS/HEDIS/CAHPS/HOS and other regulatory requirements that apply to quality programs. * Work with the data team to conduct analysis and reporting as needed on initiatives designed to impact quality performance to provide insight to future projects. * Develop annual performance improvement projects; analyze project data; and ensure completion of the finished product(s) including the development of year-end report(s). * Develop methodologies for quality program assessment (ROI and proof points of program outcomes, etc.) Qualifications * Bachelor's Degree; Master's Degree (Strongly Preferred) * Project Management/Vendor Management certification (Preferred) * 5 - 8 years of relevant, professional work experience (Required) * 3 - 5 years of Quality and/or program management experience in a managed care organization (Required) * Additional years of experience/specialized training/certifications may be considered in lieu of educational requirements (Required) * Experience in researching, developing, implementing, and assessing results of metrics and analytics (Required) * Understanding of contractual or compliance related SLAs (Required) * Ability to successfully manage multiple projects/tasks with competing priority levels and deadlines (Required) * Experience and knowledge with HEDIS/QARR, CAHPS, CMS Star Ratings, and Accreditation (Required) * Proficient in MS Office - Word, PowerPoint, Excel, Outlook (Required) * Excellent communication skills - verbal, written, presentation, interpersonal, active listening (Required) * Working knowledge of MS Access (Preferred) Additional Information * Requisition ID: 1000002308_02 * Hiring Range: $72,000-$138,000

For this position we are seeking a (RN) Registered Nurse who lives in TEXAS and must be licensed for the state of TEXAS Case Manager RN will work in remote and field setting supporting our Medicaid Star Plus population. Case Manager will be required to physically go to member's homes to complete Face to Face assessment. You will participate in interdisciplinary care team meetings for our members and ensure they have care plans based on their concerns/health needs. Members have required assessments every six months and can also require "trigger assessments" if they have hospitalizations. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position, and technical skills are needed with electronic database and Microsoft Office. TRAVEL in the field to do member visits (Mileage is reimbursed) - covering zip codes North Houston or Greater Inwood: 77064, 77065, 77088, 77092 Home office with internet connectivity of high speed required Schedule: Monday thru Friday 8:00AM to 5:00PM CST. - No weekends are Holidays **Job Summary** Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. **KNOWLEDGE/SKILLS/ABILITIES** + Completes face-to-face comprehensive assessments of members per regulated timelines. + Facilitates comprehensive waiver enrollment and disenrollment processes. + Develops and implements a case management plan, including a waiver service plan, in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. + Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. + Promotes integration of services for members including behavioral health care and long term services and supports, home and community to enhance the continuity of care for Molina members. + Assesses for medical necessity and authorize all appropriate waiver services. + Evaluates covered benefits and advise appropriately regarding funding source. + Conducts face-to-face or home visits as required. + Facilitates interdisciplinary care team meetings for approval or denial of services and informal ICT collaboration. + Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. + Assesses for barriers to care, provides care coordination and assistance to member to address psycho/social, financial, and medical obstacles concerns. + Identifies critical incidents and develops prevention plans to assure member's health and welfare. + Provides consultation, recommendations and education as appropriate to non-RN case managers + Works cases with members who have complex medical conditions and medication regimens + Conducts medication reconciliation when needed. + 50-75% travel required. **JOB QUALIFICATIONS** **Required Education** Graduate from an Accredited School of Nursing **Required Experience** + At least 1 year of experience working with persons with disabilities/chronic conditions and Long Term Services & Supports. + 1-3 years in case management, disease management, managed care or medical or behavioral health settings. + Required License, Certification, Association + Active, unrestricted State Registered Nursing license (RN) in good standing + If field work is required, Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. **State Specific Requirements** Virginia: Must have at least one year of experience working directly with individuals with Substance Use Disorders **Preferred Education** Bachelor's Degree in Nursing **Preferred Experience** + 3-5 years in case management, disease management, managed care or medical or behavioral health settings. + 1 year experience working with population who receive waiver services. **Preferred License, Certification, Association** Active and unrestricted Certified Case Manager (CCM) To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. \#PJNurse Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides general administrative support that includes routine document preparation, file management, scheduling/arranging meetings, arranging travel and ordering office supplies. May also perform a variety of activities in support of the functional processes, programs and/or services. Also provides the administration of various programs, projects and assignments aligned with functional processes and services. Work may involve design and development of program components, coordination of work effort across third party vendors or internal staff to execute against program requirements, development and monitoring of program/project metrics and ongoing process improvement. May conduct training, prepare budgeting, project scheduling, and statistical reports as required. Examples include, but are not limited, to fleet/safety administration, travel services administration, employee assistance program administration, etc. KNOWLEDGE/SKILLS/ABILITIES Assists in planning and organizing project activities. Collaborates with internal and external parties to assist with organizing the various components needed to initiate, run and conclude major projects. Retrieves data from a variety of sources for the purpose of complying with financial, legal and/or administrative requirements. Identifies and reports departmental operational issues and resource needs to the appropriate management personnel. Presents information on administrative department procedures, services, regulations, etc. for the purpose of orienting other personnel and/or disseminating information to appropriate parties. JOB QUALIFICATIONS Required Education Associate degree or equivalent combination of education and experience Required Experience 1-3 years Preferred Education Bachelor's Degree or equivalent combination of education and experience Preferred Experience 3-5 years To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

The Proposal Writer III is responsible for the writing and strategic direction of responses to Medicaid requests for proposals (RFP) and various writing tasks across the organization. Essential Functions: Responsible for writing competitive proposals for Medicaid procurements, including copy editing, fact checking, page layout, and/or proofreading as needed Works with relevant stakeholders including subject matter experts (SMEs), and executive leaders to identify, develop and gather content to respond to procurement opportunities Assist with project coordination activities, including preparing templates and coordinating production and submission activities Assists AVP, Proposal Management in managing the writing process Meet proposal related deadlines and deliverables Participate in strategy discussions to fully understand procurement requirements and how to best position the proposal response, to include terminology, approach, writing themes, etc. Writes clear and concise proposal narrative that best describes the value proposition, win themes, positioning, and CareSource's competitive or innovative advantages Ensures proposals are well written, accurate, and compliant with the requirements of the RFP/RFA request Monitors drafts for consistency, clarity, appropriateness, and persuasiveness of the material; proofread and edit content and obtain appropriate level(s) of approval for all content Works with staff to position and document operational successes and stories which can be used to support responses Communicates proposal related risks to the proposal team Collaborates with graphic designer and other stakeholders to create compelling graphics that support proposal content. Works closely with proposal team to complete content capture tool, as needed Stays current in the latest approaches to responding to Medicaid procurements and healthcare industry topics Participates in proposal-related activities, to include pre-RFP release, production and submission activities, lessons learned and debrief sessions, and/or status meetings Creates proposal-related documents, including summaries, presentations, etc. Performs any other job duties as requested Education and Experience: Bachelor's degree or equivalent years of relevant work experience is required Master's degree is preferred A minimum of five to seven (5-7) years of professional writing experience is required Experience working in deadline driven environments is required Experience with public health programs such as Medicaid, Medicare, Medicare Advantage, MLTSS, and/or other managed health care delivery programs is preferred Background with health insurance including health plan, ACO, hospital delivery system is preferred Competencies, Knowledge and Skills: Strong computer skills including knowledge of Microsoft Outlook, Word, Excel, and PowerPoint and Adobe Acrobat Excellent analytical, problem solving, and written communication skills Strong editing skills Ability to write clear, structured, articulate and persuasive responses Strong organization skills that allow the ability to manage multiple projects and deadlines Ability to work independently and within a team environment Knowledge of Medicaid, Medicare and related public health care programs is a plus Ability to accept and incorporate constructive feedback Good organizational skills. Attention to detail Must be able to work in a fast-paced environment Licensure and Certification: None Working Conditions: General office / home office environment; may be required to sit or stand for extended periods of time Up to 25% travel may be required Flexibility to work evenings, weekends and/or holidays as needed to meet deadlines, often with little notice Compensation Range: $81,400.00 - $130,200.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.

The Clinical Psychologist provides Behavioral Health coverage determination for utilization management to ensure members receive appropriate and medically necessary care in the most cost-effective setting. Essential Functions: Assume responsibility for the overall safety of patients with a BH diagnosis Serve as the clinical lead in developing and implementing evidenced based clinical policies and practices Participate in regulatory/accreditation reviews Assume key role in quality improvement initiatives, case management activities and member safety activities (i.e. incident management) Oversight and quality improvement activities associated with case management activities Provide guidance to BH orientation and network development/ recruitment in conjunction with provider relations, value-based contracting, support of episodes of care and full integration of BH services Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate Represent CareSource as the primary clinical liaison to members, providers and State agencies Support of regulatory and accreditation functions (e.g. CMS, State, NCQA and URAC) and compliance for all programs Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards Participate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives Collaborate with market/product leaders to help define market strategy Community collaborative participation Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns Provide cross-coverage for Behavioral Health Medical Directors and/or markets, as needed Support staff by providing training, clinical consultation, and clinical case review for members including Medical Advisement meetings Perform any other job related instructions, as requested Education and Experience: Completion of an accredited clinical psychology program is required Successful completion of a doctoral internship program in psychology is required Minimum of three (3) years of clinical practice experience is required Managed care medical review/medical director experience is preferred Competencies, Knowledge and Skills: Basic Microsoft Word skills Excellent communication skills, both written and oral Ability to work well independently and within a team environment Ability to create strong relationships with Providers and Members Previous Institute for Healthcare Improvement (IHI) or equivalent training participation is preferred High ethical standards Attention to detail Critical listening and systematic thinking skills Ability to maintain confidentiality and act in the company's best interest Ability to act with diplomacy and sensitivity to cultural diversity Decision making/problem solving skills Conflict resolution skills Strong sense of mission and commitment of time, effort and resources to the betterment of the communities served Ability to analyze healthcare data from a variety of sources to evaluate physician practice patterns Leadership experience and skills Licensure and Certification: Current, unrestricted license to practice psychology in state of practice as necessary to meet regulatory requirements is required MCG Certification is required or must be obtained within six (6) months of hire Working Conditions: General office environment; required to use general office equipment May be required to work evenings/weekends May be required to travel in-state to fulfill duties of position Compensation Range: $92,300.00 - $161,600.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.#LI-SW2

**Shift:** Monday - Friday 10:30am - 7:00pm CST Provides customer support and stellar service to meet the needs of our Molina members and providers. Resolves issues and addresses needs fairly and effectively, while demonstrating Molina values in their actions. Provides product and service information, and identifies opportunities to improve our member and provider experiences. **Job Duties** - Provide service support to members and/or providers using one or more contact center communication channels and across multiple states and/or products. To include, but not limited to, phone, chat, email, and off phone work supporting our Medicaid, Medicare and/or Marketplace business. - Conduct varies surveys related to health assessments and member/provider satisfaction. - Accurately document pertinent details related to Member or Provider inquiries. - Ability to work regularly scheduled shifts within our hours of operation, where lunches and breaks are scheduled and work over-time and/or weekends, as needed. - Demonstrate ability to quickly build rapport and respond to customers in an empathetic manner by identifying and exceeding customer expectations. - Aptitude to listen attentively, capture relevant information, and identify Member or Provider's inquiries and concerns. - Capable of meeting/ exceeding individual performance goals established for the position in the areas of: Call Quality, Attendance, Adherence and other Contact Center objectives. - Able to proactively engage and collaborate with varies Internal/ External departments. - Personal responsibility and accountability by taking ownership of providing resolutions in real time or through timely follow up with the Member and/or Provider. - Supports provider needs for basic inquiries and assistance involving member eligibility and covered benefits, Provider Portal, and status of submitted claims. - Ability to effectively communicate in a professionally setting. **Job Qualifications** **REQUIRED EDUCATION** : HS Diploma or equivalent combination of education and experience **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES** : 1-3 years Sales and/or Customer Service experience in a fast paced, high volume environment **PREFERRED EDUCATION** : Associate's Degree or equivalent combination of education and experience **PREFERRED EXPERIENCE** : + 1-3 years + Preferred Systems Training: + Microsoft Office + Genesys + Salesforce + Pega + QNXT + CRM + Verint + Kronos + Microsoft Teams + Video Conferencing + CVS Caremark + Availity To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $15 - $24.02 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Full Stack Test Automation Architect (GenAI and .NET) - Local/Relocation is preferred The Configuration Department at CareSource operates as an R&D work environment, where innovation, collaboration, and high-performance drive success. As an architect in this team, you'll have the opportunity to foster cutting-edge automation strategies, working in a culture that emphasizes continuous improvement, transparency, and mutual respect. This dynamic environment encourages bold ideas and breakthrough innovations in test automation, empowering architects to push boundaries and set new industry standards in Facets and GuidingCare configuration. If you thrive in a space where strategic vision meets hands-on execution, this is the place to lead, innovate, and make a lasting impact. We are seeking a Test Engineering Automation Architect with 10+ years of experience in the healthcare payor domain, specifically in Facets and GuidingCare configuration. This role is an opportunity to lead automation transformation within a high-performing Configuration Operations department that maintains near-zero production defect leakage and ensures strict SLA compliance. Strategic Leadership: Spearhead test automation transformation initiatives to accelerate testing cycles Hypercare: Provide support of test automation servers and utilities, ensuring optimal performance, swift bug fixes, and 100% automation adoption with user-friendly utilities AI Technical expertise: Experienced in Generative AI technologies and large language models (e.g., GPT-4o), with expertise in designing and deploying end-to-end AI architectures to address testing challenges in Facets/GuidingCare. Proficient in Python scripting and leveraging advanced AI frameworks to automate processes, enhance efficiency, and expand test coverage. .NET Technical expertise: Experienced in C#, .NET Core, ASP.NET MVC, and Web Forms, with a strong grasp of repository patterns and development in Visual Studio. Advanced expertise in Microsoft SQL Server, specializing in query optimization, stored procedures, views, and triggers, with hands-on experience in TriZetto Facets database architecture for data validation. Highly proficient in SQL for complex querying, data extraction, management, and optimization, with advanced capabilities in data analysis-seamlessly transferring data from SQL to Excel and utilizing pivot tables for insightful reporting. Skilled in test automation development and maintenance, leveraging C# .NET to enhance test coverage, streamline processes, and drive automation tool adoption. Proficient in source code management (Git), debugging complex utilities, and developing enhancements, with the ability to create proof-of-concept solutions for technology migrations (e.g., UFT to OpenAI). Automation Collaboration & Leadership: Proven expertise in driving end-to-end test automation adoption, optimizing processes, and delivering high ROI through strategic automation initiatives. Skilled in cost optimization, business case development, and automation strategy execution, ensuring alignment with sprint goals and SLA-driven deliverables. Collaborates with AI architects, RPA experts, and engineers to implement AI-driven automation strategies while effectively communicating business value to executive leadership. Continuously integrates industry best practices to enhance automation frameworks, streamline workflows, and drive innovation. Education and Experience: Associate's degree or equivalent years of relevant work experience is required Minimum of 10+ years of health plan business or systems solutions experience is required Exposure to Facets/ GuidingCare or equivalent system is preferred Hands on experience is must Licensure and Certification: .NET Development Certifications (C#/.NET framework expertise) Microsoft SQL Server Certification (Azure, Database management & optimization) GenAI Certifications (AI-driven automation & data intelligence) Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation Range: $92,300.00 - $161,600.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.#LI-GB1

The Director, State Government Affairs serves as an advocate for CareSource business priorities and Medicaid & Medicare managed care on a state level. Essential Functions: Develop, implement and lead a strategic approach to advocacy efforts and coordinate, facilitate and advance business leadership priorities at the state level Serve as primary liaison between CareSource and state elected officials, administration members and other key state organizations Develop and implement an effective government affairs program in our strategic states to position CareSource and its health plans in a positive manner with key governmental stakeholders and to further its mission and strategic objectives Collaborate with state trade associations on key policy issues and aligned advocacy objectives Develop and implement strategic advocacy strategies in conjunction with the marketing and community services staff, to support and advance corporate strategic goals Monitor and research emerging industry, policy and regulatory changes at state levels for analysis and integration into the corporate business development plan Participate in the development of key partnerships with external agencies, associations and consumer advocacy coalitions and other external stakeholders Lead/manage contract lobby resources in various states Participate in the development of the annual strategy for the corporate PAC to effectively support and protect issues critical to CareSource' interests Perform any other job duties as requested Education and Experience: Bachelor's degree in health/public policy, public administration, business administration or related field or equivalent work experience is required Relevant master's degree in health policy, public policy, public administration or other related discipline or equivalent work experience is preferred Minimum of five (5) years of senior leadership experience in public sector/not-for-profit policy development and advocacy is required Minimum of three (3) years planning and strategy development experience is required Minimum three (3) years of experience with Medicaid & Medicare managed care and other public health care programs is required Competencies, Knowledge and Skills: Thorough understanding of legislative processes at local, state and federal levels and lobbying experience with a primary concentration in policy legislative issues Strong working knowledge of Medicaid , Medicare and managed care laws, regulations and financing models Intermediate proficiency level with Microsoft Office Broad internet research skills Technical writing skills Excellent written and oral communications skills Legislative advocacy skills Understanding of the public policy process Strategic thinker with negotiation skills Strong analytic, research and organizational skills Knowledge and experience with publicly funded health care programs Licensure and Certification: Certified Healthcare Insurance Executive (CHIE) is preferred Working Conditions: General office environment; may be required to sit or stand for extended periods of time Ability to travel as required by the needs of the business Compensation Range: $110,800.00 - $193,800.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.#LI-SW2

Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members enrolled with a CareSource Management Group line of business, as well as monitoring the delivery of healthcare services in a cost effective manner. Essential Functions: Complete prospective, concurrent and retrospective review of acute inpatient admissions, post acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner Refer cases to CareSource Medical Directors when clinical criterial is not met or case conference is needed/appropriate Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Document, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care Provide guidance to non-clinical medical management staff Provide guidance to and assist with oversight of LPN medical management staff Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job-related instructions, as requested Education and Experience: Completion of an accredited registered nursing (RN) degree program is required Minimum of three (3) years clinical experience is required Med/surgical, emergency acute clinical care or home health experience is preferred Utilization Management/Utilization Review experience is preferred Medicaid/Medicare/Commercial experience is preferred Competencies, Knowledge and Skills: Basic data entry skills and internet utilization skills Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Familiarity of the healthcare field Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice is required MCG Certification is required or must be obtained within six (6) months of hire Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation Range: $61,500.00 - $98,400.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.#LI-JM1

The Health Plan Data Analyst II is responsible for extracting, analyzing, reporting, tracking and monitoring provider data across business functions, systems and interfaces. Essential Functions: Participate as a member of Health Partner Lifecycle (HPLC) team to support existing provider data operations and new market implementations Perform disruption analysis activities for assigned markets Assimilate large quantities and/or complicated data into meaningful formats for tracking and status requirements Serve as Project Manager for select HPLC initiatives In conjunction with HPLC management team, develop Performance Improvement initiatives/corrective action plans to improve quality of provider data and network development In conjunction with HPLC management team, coordinate activities with regard to provider network data management and reporting Develop database structures and reports as needed Develop queries to aid in information retrieval, validation and updating of provider databases Review provider organizations and systems for development of analyses that support contract negotiation and provider recruitment processes Work with both internal and external partners to gain information for provider network reporting and analyses Coordinate and track all State files, hospital, physician and ancillary recruitment information Prepare NCQA documentation for assigned markets as appropriate Act as Subject Matter Expert for provider data and impacts to downstream processes Perform any other job duties as requested Education and Experience: Bachelor's degree or equivalent years of relevant work experience is required Minimum of three (3) years of data analysis or experience in a health care setting is required Experience with Cognizant Facets Provider application is required Managed care experience is preferred Project management experience is preferred Competencies, Knowledge and Skills: Advanced Microsoft Excel, Access, and Word skills Knowledge and understanding of Facets data model Proficient in data analysis and use of analytics / reporting tools such as Power BI Demonstrates analytical and supporting technical skills to include SQL capabilities Experience with Visio and PowerPoint preferred Working knowledge of provider data repositories and directories preferred Ability to work independently and within a team environment Excellent written and verbal communication skills Ability to meet tight deadlines Extreme flexibility as projects and priorities shift Licensure and Certification: None Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation Range: $61,500.00 - $98,400.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.#LI-EM1

The Configuration Systems Analyst III is responsible for managing and defining system configuration requirements. Desired Automation experience. Essential Functions: Manage and define system configuration requirements. Responsibility for requirements, definition, document, design, testing, training and implementation support using appropriate templates or analysis tool Develop and utilize reports to analyze and stratify data in order to address gaps and provide answers to issues identified within the department or by other departments Identify, manage and document the status of open issues, configuration design, and final resolution within change management system Review and interpret regulatory items, timely delivery of required updates Development of standard code set and reimbursement design templates Plan and implement new software releases including testing and training Participate in meetings with business owners, users and IT to achieve solutions that meet the requirements and expectation of CareSource Lead configuration initiatives in payment policy meetings and present to committees Coordinate annual benefit changes with internal resources Provide analysis of efficiencies related to system enhancement and automation. Review, analyze, and document effectiveness and efficiency of existing systems and develop strategies for improving or further leveraging systems Manage the reimbursement review. Identify and design appropriate changes. Lead the development and execution of test plans and scenarios for all reimbursement designs for core business system and related processes Audit configuration to ensure accuracy and internal controls to minimize fraud and abuse and overpayment related issues Anticipate and identify customer needs and match products and services to facilitate the fulfillment of those needs Ensure system processes and documents exist as basis for system logic Manage resources and communications to facilitate work completion Mentor the use of tools to define requirements Perform any other job duties as requested Education and Experience: High School Diploma or GED is required Bachelor's degree or equivalent years of relevant work experience is preferred A minimum of five (5) years of health plan experience, to include three (3) years of configuration or clinical editing software experience is required Exposure to Facets or equivalent system is preferred Competencies, Knowledge and Skills: Exceptional computer skills and abilities in Facets Advanced proficiency Microsoft Suite to include Word, Excel, Access and Visio Proven understanding of database relationships required Understanding of DRG and APC reimbursement methods Understanding of CPT, HCPCs and ICD-CM Codes Knowledge of HIPAA Transaction Codes Effective listening and critical thinking skills Effective problem solving skills with attention to detail Excellent written and verbal communication skills Ability to work independently and within a team environment Strong interpersonal skills and high level of professionalism Ability to develop, prioritize and accomplish goals Understanding of the healthcare field and knowledge of Medicaid and Medicare Proper medical coding knowledge and claims processing skills Customer service oriented Facets knowledge/training Ability to manage vendor relationships Licensure and Certification: Certified Medical Coder (CPC) is preferred Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation Range: $81,400.00 - $130,200.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.#LI-GB1

divstrong Description/strongbr/pstrong JOB DESCRIPTION/strong/p pstrong Job Summary/strong/p pMolina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service./p pThis position will be supporting our Washington State Plan. We are seeking a Registered Nurse with previous knowledge of behavioral health services, substance abuse, physical health/disease management, and long-term care. The candidate should also have experience supporting social service needs, possess community resources, and health promotion experience. The Health Home Care Coordinator must be comfortable with outreach calling to educate and enroll new potential members. Bilingual candidates are encouraged to apply. Further details will be discussed during the interview process. /p pWork schedule Monday- Friday 8:00 AM to 5:00 PM PST/p pRemote position- 50% with field travel- 50% within Centralia and Chehalis- Lewis County/p pWashington RN licensure required/p pstrong KNOWLEDGE/SKILLS/ABILITIES/strong/p ul li Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment./li li Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals./li li Conducts face-to-face or home visits as required./li li Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly./li li Maintains ongoing member case load for regular outreach and management./li li Promotes integration of services for members including behavioral health care and long term services and supports/home and community to enhance the continuity of care for Molina members./li li Facilitates interdisciplinary care team meetings and informal ICT collaboration./li li Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts./li li Assesses for barriers to care, provides care coordination and assistance to member to address concerns./li li25- 40% local travel required./li li RNs provide consultation, recommendations and education as appropriate to non-RN case managers./li li RNs are assigned cases with members who have complex medical conditions and medication regimens/li li RNs conduct medication reconciliation when needed./li /ul pstrong JOB QUALIFICATIONS/strong/p pstrong Required Education/strong/p pGraduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred./p pstrong Required Experience/strong/p p1-3 years in case management, disease management, managed care or medical or behavioral health settings./p pstrong Required License, Certification, Association/strong/p pActive, unrestricted State Registered Nursing (RN) license in good standing./p pMust have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation./p pstrong Preferred Education/strong/p pBachelor's Degree in Nursing/p pstrong Preferred Experience/strong/p p3-5 years in case management, disease management, managed care or medical or behavioral health settings./p pPreferred License, Certification, Association/p pActive, unrestricted Certified Case Manager (CCM)/p p /p p /p pTo all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing./p pMolina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V./p p#PJNurse/pbr/br//div

The Director, Claims Life Cycle Management and Implementation is entrusted with overseeing and directing the strategic enhancement of claim outcomes across existing and emerging lines of business within the Claims organization. This pivotal role involves orchestrating collaborative efforts with cross-functional teams to devise and implement project strategies, mitigate risks, monitor progress, lead process optimization endeavors, and create transformative change. Expert-level comprehension of the end-to-end claims process, adept project management skills, and exceptional communication and interpersonal abilities are imperative for success. Essential Functions: Define and influence the functional requirements of Facets provider, configuration, and claims end-to-end adjudication processes, encompassing claim intake, pre-adjudication, adjudication, post-adjudication, and payment procedures Develop and ensure execution of implementation plans, including timelines, budgets, and resource allocation, while ensuring risk management and adherence to project milestone Be the conduit between technical and business perspectives, guaranteeing that technical solutions align seamlessly with business imperatives Collaborate with business, architecture, and infrastructure units to uphold exceptional service levels and bolster stakeholder satisfaction Lead the seamless implementation of new lines of business within the Claims organization, proactively identifying future system enhancements and opportunities Perform detailed analysis of data, workflows, policies, procedures, organization of staff, skills and offer potential solutions to execute growth initiatives Oversee the analysis of business processes and development of functional requirements and appropriately document and communicate captured information for validation and re-usability Maintain diligent oversight of project progress, providing regular updates to stakeholders and driving consensus to ensure project integrity and efficacy Manage risk and ensure implementation activities are completed on time and within budget Conduct intricate data analysis, workflow evaluations, and policy assessments to propose and execute initiatives aimed at refining operational efficiency and resolving complex technology and process-based challenges Organize work teams, drive consensus, and ensure end-to-end policy and process integrity to accomplish project work, including stakeholder participation; establishment of a project plan; meeting facilitation; consensus building; recommendation and decision documentation, and implementation oversight Stay abreast of industry best practices and regulatory mandates, integrating them into claims processes to ensure adherence and compliance Ensure compliance with regulatory and contract obligations in new business implementations Foster a culture of continuous improvement, contributing to the development and enhancement of claims processes, while nurturing a high-performance team environment Perform any other job duties as requested Education and Experience: Bachelor's degree in business administration, healthcare administration, or a related field, or equivalent years of relevant work experience is required Minimum of five (5) years of progressive experience in healthcare claims management or a related field is required Minimum of three (3) years of project management experience is required Facets experience is required Management/leadership experience is required Competencies, Knowledge and Skills: Advanced skills in Microsoft Office suite Proven track record of successfully implementing new managed care products Exceptional project management acumen, and a proven track record of successfully implementing new managed care products Expert understanding of claims processes, Facets, pre-adjudication, post-adjudication, Checkwrite, Mass Claims Adjustments, Batch Processing, Remittance Advice process, reimbursement methodology, and project management toolsets Demonstrated strategic acumen and ability to drive operational excellence Outstanding communication skills, both written and verbal Effective listening and critical thinking skills Demonstrated strong problem-solving and decision making skills Ability to create and maintain effective working relationships Licensure and Certification: Project Management Professional (PMP) certification preferred Working Conditions: Standard office environment with potential for extended periods of sitting or standing Occasional travel may be required based on business needs Compensation Range: $110,800.00 - $193,800.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.

The Regional Provider Engagement Manager is a key member of the Provider Engagement team, supporting EviCore's solutions by working directly with the provider community and health plan partners across nine states: Arizona, New Mexico, Texas, California, Utah, Hawaii, Colorado, Alaska, and Nevada. This position is responsible for training providers on EviCore's prior authorization processes, promoting process improvement, and supporting market readiness efforts. The role includes managing provider relationships, delivering educational outreach, and collaborating across internal departments to optimize the provider experience and ensure seamless implementation of our solutions/programs. The Manager will support various programs, including Cardiovascular, Gastroenterology, Laboratory Management, Medical Oncology, Musculoskeletal, Radiation Oncology, Radiology, and Sleep, among others. The individual will serve as a subject matter expert and collaborate cross-functionally with teams such as Sales, Implementation, Program and Operations. Duties and Responsibilities: Create and oversee market readiness strategy Collaborate with other departments to fulfill provider engagement duties that lead to a successful implementation Develop and lead in training sessions to providers, delivering effective verbal and written communications appropriate to the audience Conduct provider outreach activities as needed based on direction provided by our health plan partners, Client management team and other areas of the business Proactively identify and respond to issues and trends affecting multiple providers Lead and coordinate communication with providers, providing timely status of efforts to resolve escalated, complex, and sensitive provider issues in collaboration with other internal departments at EviCore Provide education to provider personnel to improve overall process efficiency that is patient-centric and educates providers on EviCore products and services Engage appropriate provider staff regarding evi Core initiatives to ensure optimal impact of overall project efforts and outcome Ensure knowledge of all solutions/programs across organization Facilitate meetings with provider groups that may include clinical discussion and follow-up to each meeting with applicable research and issue resolution Track and document all provider outreach interactions Assist with the development and management of policies and procedures relating to provider participation including management and production of online provider materials and production of provider newsletters Develop and manage relationships with providers, monitoring and reviewing key metrics and overall activity performance Generate and analyze reports to share with provider groups to deliver pertinent information to providers to assist with process efficiency Work with appropriate departments to develop and manage comprehensive provider reporting packages and issue tracking for assigned territory Interact with other internal staff members to provide support with special projects or assignments Position Requirements: Bachelor's degree in Business, Healthcare, related field or equivalent work experience 5+ years of experience in provider relations or a similar role Strong oral, written, and interpersonal communication skills Proven ability to lead projects and present information effectively Strong organizational, analytical, and problem-solving skills Excellent project and time management capabilities Up to 25% travel required across assigned states; travel may be limited due to public health guidelines This is a hybrid role and will likely require the ability to work in-person. If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. About Evernorth Health Services Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you require reasonable accommodation in completing the online application process, please email: ********************* for support. Do not email ********************* for an update on your application or to provide your resume as you will not receive a response. The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

The Team Lead, Claims Oversight is responsible for managing and maintaining policy and performance of claim adjudication and implementation activities to ensure performance objectives are met. Essential Functions: Responsible for day-to-day activities surrounding the knowledge and insight around development and support of process enhancements and process automation opportunities Engage in new product implementations including SME support and representation on behalf of Claims driving accurate, efficient claim processes from ideation through implementation. Manage and maintain workflow/assignments to ensure timely processing of claims Ensure prompt pay requirements are met and maintained on a daily basis Monitor and analyze performance trending including processing efficiency and optimal processor specialization/concentrations Document process changes and new procedures to promote consistency in claims operations Monitor level of intakes, email, mail and special projects; notify management of levels outside of established thresholds Create, review, revise and enforce company and department policies and procedures Responsible for direct supervision of staff including quality review, performance feedback, disciplinary issues and merit/bonus appraisal review Oversee orientation and training needs of new claims representatives Observe staff's ability to utilize computer system and reference materials and make recommendations for improving performance as appropriate Participate in managing external vendor relationships Perform any other job duties as requested Education and Experience: Bachelor Degree or equivalent years of relevant work/education experience required Minimum three (3) years claims processing experience in an HMO or related industry is required Minimum two (2) years data analysis experience required Previous supervisory/leadership experience required Leadership experience of claims processing via TriZetto Facets highly preferred Competencies, Knowledge and Skills: Intermediate level skills in Microsoft Word, Excel and Outlook Facets or equivalent claims adjudication system knowledge required Effective written and verbal communication skills Leadership experience and skills Proven ability to lead work efforts with or without staff reporting responsibility Ability to work independently and within a team environment Strong attention to detail Ability to effectively support diverse personalities and work styles Excellent critical thinking and listening skills Training/teaching skills Strategic management skills Proper grammar usage Time management skills Customer service orientation Decision making/problem solving skills Knowledge of claims related applications and software Demonstrated ability to identify and recommend process improvements Licensure and Certification: None Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation Range: $70,800.00 - $113,200.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.#LI-RW1

The Compliance Analyst III is a professional compliance role responsible for supporting the Compliance program by focusing on areas of risk assessment to effectively stratify compliance risk, detection of non-compliance through various compliance activities, and corrective action support for identified issues of non-compliance. This role is critical to assist the organization to determine adherence to internal standards and government/contractual requirements as they apply to the products, services, and/or operational areas assigned. Essential Functions: Provide Compliance Program support with audit and monitoring, corrective action management, data analytics and other projects to ensure proper execution of the Compliance Program workplan and priorities Support the Compliance Program by collaborating and oversight of high risk areas to ensure that the compliance program is effective and efficient in identifying, preventing, detecting, and correcting non-compliance Assist in execution of risk assessment, work plan, and other compliance activities Support implementation, policy and procedure creations, training, education, and external reviews Provide expert analysis, interpretation, training and education related to regulatory requirements as needed to ensure understanding and effective implementation of compliance requirements and provide related guidance Provides Business Area support related to requirements as needed to ensure understanding and effective implementation of compliance requirements Support departments with requirement implementation, including implementation of the health plans' business and contractual requirements, reporting development, policy & procedure development/review, and readiness testing Assist Compliance Management in development and performance of the annual compliance audit and monitoring workplans and activities using the proper Corporate Compliance tools in an effort to detect issues of non-compliance Plan and execute audit and monitoring activities Proactively use analytic and research skills to identify potential areas of risk to CareSource and timely make recommendations or escalate to Compliance Management for issue management, external audit enforcement trending, and related industry corrective actions Ensure timely, complete, accurate, and concise documentation of corrective action plans, case summaries and executive summaries for all compliance matters. Documentation must include problem, history, mitigation or corrective actions, and recommendations for ongoing monitoring or process improvement Develop and maintain corrective action plan information through conclusion Lead research, root cause and gap analysis Analyze deficiencies to determine root cause of non-compliance to effectively and thoroughly address the matter and fully develop appropriate corrective actions accordingly Lead quality orientation, follow procedures, ensure high-quality output, and take action to correct deficiencies Maintain information in compliance tools as required Develop and maintain positive and strategic relationships with internal and external stakeholders Support management onboarding of new team members through mentorship, shadowing, and training of all required functions and processes Assists in review and dissemination to team of Regulatory Distribution Management items (new and changing regulations); works to understand and provide SME to team on these items and the impact to our work with high-risk business areas Manage State/Federal Regulator inquiries Perform any other job duties as requested Education and Experience: Bachelor's degree in business or related field, or equivalent years of relevant work experience is required Minimum of five (5) years of compliance and/or regulatory experience and experience with Government Program products is required Previous experience in corporate compliance, delegation management, internal or external audit, or other assurance function is strongly preferred Competencies, Knowledge and Skills: Strong familiarity with government-funded healthcare programs, including Medicaid, Marketplace, and Medicare, and the compliance standards imposed upon First Tier, Downstream and Related (FDR) entities Advanced ability to perform data analysis to produce meaningful insight and drive appropriate action Familiarity with healthcare operations and/or clinical concepts, practices and procedures Demonstrated understanding of compliance and regulatory fundamentals specifically related to managed care and government programs (CMS/HHS/DOI/Medicaid) Knowledge of internal and external audit functions and procedures Ability to conduct research and analysis of Federal, State, and relevant industry regulatory and enforcement Advanced ability to directly interact with Regulators Demonstrated expert level professional written and verbal communication skills, to include proper grammar usage, document structure, and business writing to audiences including but not limited to internal Leadership at all levels, internal and external Legal Counsel, Corporate Compliance, State and Federal Regulators Ability to organize multiple schedules to ensure all required individuals are able to attend critical compliance meetings, audit conferences, onsite or virtual audit sessions, and/or Vendor reviews Expert at effectively managing work, prioritizes, makes preparations, schedules effectively, leverages resources, and remains focused Expert ability to implement and manage change Expert ability to work independently and in a collaborative, cross-functional environment Demonstrated success in working in a matrixed environment Expert in maintaining positive strategic relationships Expert level attention to detail Expert critical thinking skills Expert in organizational/project management skills/scheduling skills Proven negotiation skills/experience Time management skills including creation and maintenance of project timelines Advanced level experience in Microsoft Word, Excel and PowerPoint Expert reading and comprehension skills Expert in decision making/problem solving skills Expert experience for administrative responsibilities Minimal supervision required Licensure and Certification: Certified in Healthcare Compliance (CHC) or Certified Compliance and Ethics Professional (CCEP) preferred Current, unrestricted clinical licensure to include: Licensed Practical Nurse (LPN) in state of service, Registered Nurse (RN) in the state of service, or other clinical licensure may be desired for positions with a clinical focus Functional business licensure/certification may be desired as they apply to organizational operations (e.g. Claims coding certification, analytics certification, etc.) Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation Range: $70,800.00 - $113,200.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.#LI-RW1

The EDI/Edifecs Developer III is responsible for the designing, coding, testing, and analyzing software programs and applications including research, design, documenting and modifying throughout the production lifecycle. Essential Functions: Analyze, Design, code and test software through the production lifecycle according to functional/technical specifications that meet business requirements Run and monitor software performance tests on new and existing software for the purposes of correcting errors, isolating areas for improvement, and general debugging Administer critical analysis of test results and deliver solutions to problem areas Assist in software deployment as required based on build specification Liaise with network administrators, systems analysts, and software engineers to assist in resolving problems with software products or company software systems Perform technical code reviews of peers to ensure that proper coding methodology is being adhered to Work within an iterative approach methodology Triage and work incident management requests Maintain an understanding of software development life cycle (SDLC), continuous integration/continuous delivery (CI/CD), and configuration management Sets objectives for own job with the understanding of how output would affect and impact other job areas related to own job. Contributes and provides input to the development of operational area goals within the context of own job area. Work consists of tasks that are typically not routine, works independently and applies discretion within established operational boundaries and procedures. Work direction is only provided for new areas of work or unique assignments. Applies specialized job knowledge of own job area within a department; may have working knowledge of other related job areas Perform any other job duties as requested Education and Experience: Bachelor of Science in the field of computer science or software engineering or equivalent years of relevant work experience required Minimum of five (5) years of advanced OOP principles and design experience required Experience leading a development team is preferred Experience developing and designing n-tier applications with multi-tier architectures is preferred UML Modeling experience is preferred Coding experience, Java, API, Microservices and Python AI/ML and Cloud experience Competencies, Knowledge and Skills: Strong EDIFECS Application Skills with all aspects of the product required Familiarity with Realtime and Batch HealthCare EDI Transactions required GITHUB experience; HIPAA Gateway; and Facets a plus Familiarity with HealthCare Trading Partner technology a plus Hands on experience working in integrated development environments Hands-on software troubleshooting experience Experience with specific phases of the software development life cycle, especially Agile, Test Driven Development, and Waterfall Strong interpersonal skills including excellent written and verbal communication skills Knowledge of configuration management tools, scripting, programming and automated testing tool sets Flexible and adaptable in regards to learning and understanding new technologies Highly self-motivated and directed, technically proficient, highly logical with strong attention to detail Proven analytical and problem-solving abilities Ability to effectively prioritize and execute tasks while working both independently and in a team-oriented, collaborative environment Innovative and pioneering spirit Licensure and Certification: Certifications in technical tools and/or programming languages preferred (MCSD, Java, Onbase, Tibco, SAP, etc.) Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation Range: $81,400.00 - $130,200.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Create an Inclusive Environment Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.