Job Summary: The Team Lead, Program Integrity drives and encourages innovative investigative processes and workflows to reduce turnaround time and produce positive investigative outcomes. Essential Functions: Direct the day-to-day activities and leadership of investigative staff to ensure
Job Summary: The Director, Pharmacy Clinical Strategy leads the strategic development of formulary management best practices & industry-leading, market-competitive formulary and medical drug strategies across all CareSource lines of business and markets. Essential Functions: Ensures the
Job Summary: The Provider Contracting Analyst II supports the development, validation, and optimization of provider reimbursement strategies through advanced data analysis, financial modeling, and AI-enabled analytic tools. This role is responsible for evaluating provider payment methodologies,
Job Summary: The Market Behavioral Health Medical Director is responsible for the overall safety of patients with a Behavioral Health diagnosis, with a special focus on safe prescribing. Essential Functions: Assume responsibility for the overall safety
Job Summary: Vice President, Actuarial - Product is responsible for driving company strategy and managing actuarial expertise in coordination with other leaders on all aspects of CareSource’s rate levels to ensure actuarial soundness, and to use
Job Summary: The Managing Actuary provides leadership and direction to ensure team goals and strategies are successfully achieved. Essential Functions: Responsible for pricing, forecasting, reserving or other actuarial processes including development of key assumptions, as well as
Job Summary: The Operations Specialist II provides analytical support and leadership for project impacting Claims and key internal Claims projects. Essential Functions: Represent claims on cross-functional project work teams Submit, monitor and prioritize IT tickets for the
Job Summary: The Behavioral Health Medical Director is responsible for the overall safety of patients with a BH diagnosis, with a special focus on safe prescribing. Essential Functions: Assume responsibility for the overall safety of patients
Job Summary: 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
Job Summary: The Operations Regulatory Specialist II provides analytical support and leadership for key internal Operations projects and partners with the Operations departments to ensure all regulatory and compliance deliverables are met. This position will work
Job Summary: The Employee Relations Partner III serves as a strategic advisor on employee relations, partnering with business leaders, HR Business Partners, and CoEs to strengthen organizational practices and advance enterprise initiatives. This role helps shape
Job Summary: The Human Resources Business Partner III serves as a strategic partner to senior leaders, aligning HR strategies and initiatives with business objectives and organizational culture. Essential Functions: Serve as a trusted advisor to senior
Job Summary: The Board-Certified Behavior Analyst serves as the clinical lead in developing and implementing evidenced based clinical policies and practices for members with Autism and their families Essential Functions: Oversee coverage determinations for ABA utilization
Job Summary: The Health Plan Data Analyst III is responsible for extracting, analyzing, reporting, tracking and monitoring provider data across business functions, systems and interfaces. Additional responsibilities include analyzing data operations to support building new solutions
Job Summary: The Program Integrity Medical Coding Reviewer III supports most complex medical record audit programs, dispute management, escalation management and generates concise in-depth reporting and analysis to track performance related to the Pre-Pay and Post-Paid
Job Summary: The Business Analyst IV is a senior-level position responsible for driving strategic initiatives and leading cross-functional teams to deliver innovative solutions that address complex business challenges. This role bridges the gap between business needs and
Job Summary: The LTSS & Dual Eligible Report Engineer IV will play a crucial role in utilizing data analytics to drive informed decision-making and optimize business processes within the healthcare environment. This senior-level position is responsible
Job Summary: The Claims AI Business Analyst IV is responsible for driving end-to-end process transformation initiatives across Claims Operations by leveraging automation and artificial intelligence (AI) to improve efficiency, reduce costs, and enhance quality. This role
Job Summary: Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services)
Job Summary: The Manager, Pharmacy Benefit Management is responsible for managing a team and overseeing the day-to-day operations associated with regulatory activity, PBM oversight, performance and monitoring, pharmacy audit activity, pharmacy compliance business owner tasks as well