CareSource

Nurse

• Provide monitoring, follow-up, and clinical care management to dually eligible enrollees with complex medical, behavioral, and social care needs
• Engage enrollees in homes and community settings to establish complex care management relationships
• Liaise between healthcare providers, community resources, and enrollees to coordinate communication and care transitions
• Perform comprehensive, functional, crisis, and risk assessments
• Develop and update care plans with enrollees
• Lead interdisciplinary care teams and collaborate with internal and external peers
• Oversee utilization of long-term services and supports
• Assist members with housing, transportation, food assistance, and social services
• Educate members and families about Medicare, Medicaid, chronic conditions, medication adherence, preventive care, and healthy lifestyles
• Support preventive health strategies and close care gaps
• Follow up after hospitalizations and significant health events to promote continuity and prevent readmissions
• Coordinate with physicians, specialists, community organizations, state agencies, and service providers
• Advocate for enrollee needs and preferences
• Evaluate member satisfaction and monitor concerns
• Conduct regular member, provider, and community-based visits
• Report abuse, neglect, or exploitation as a mandated reporter
• Adhere to NCQA and Care Management standards
• Perform other related duties as requested

Registered Nurse (RN) Care Manager

Team Lead

• Provide direct oversight of Clinical Care Review employees and oversee day-to-day workflow within the CCR team
• Ensure direct reports meet minimum quality and productivity standards
• Analyze health condition and service complexities
• Develop workload management plans based on trend analysis and advocate for the CCR team
• Provide feedback, guidance, orientation, training, and ongoing resources to CCRs and the pre-authorization team
• Standardize activity and outcome reporting for department initiatives and programs, including documentation required by the State and accrediting bodies
• Perform utilization review and discharge planning activities for CareSource members
• Monitor appropriate, cost-effective delivery of healthcare services
• Assist with process improvement activities and refine processes supporting cost-effective utilization and appropriate levels of care
• Liaise with Care Management, Claims, Enrollment, Customer Service, and other areas to resolve problems
• Audit CCR team members for compliance with CareSource policies, processes, regulatory requirements, NCQA guidelines, and URAC guidelines
• Provide input into team evaluations and assist with team goal development
• Design and present utilization management informational meetings
• Attend state hearings as necessary
• Perform other requested job duties

Team Lead, Clinical Care Review

Medical Director

• Provide clinical review services and clinical case review for members
• Participate in peer-to-peer discussions
• Provide provider education, training, data sharing, performance evaluations, and orientation to the plan
• Conduct clinical reviews for designated CareSource members
• Provide physician review for clinical appeals cases
• Evaluate and investigate suspected fraud, abuse, and quality-of-care concerns
• Develop policies, procedures, clinical care standards, practice guidelines, Quality Improvement Plans, and corporate quality initiatives
• Participate in quality improvement, case management, member safety, regulatory, accreditation, and compliance activities
• Provide cross-coverage for other Medical Directors and/or markets
• Review utilization data to identify pattern variances and provide feedback and education
• Collaborate with market and product leaders to define market strategy
• Participate in community collaboratives
• For MCR assignments, serve as physician reviewer for post-service clinical audits and payment integrity activities involving high-dollar claims, HACs, quality-of-care concerns, and other claims requiring medical judgment
• Evaluate medical records, clinical documentation, claims data, and audit findings to determine medical necessity, clinical appropriateness, quality-of-care considerations, and payment recovery opportunities
• Partner with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics teams
• Support provider discussions, audit findings, disputes, appeals, and continuous improvement initiatives for the enterprise MCR capability
• Perform other job-related duties as requested

Medical Director, Post-Service Review, Medical Claims Review

Manager

• Provide monitoring, follow-up, and clinical care management to dually eligible enrollees with complex medical, behavioral, and social needs
• Engage enrollees in homes and community settings to establish complex care management relationships
• Liaise between healthcare providers, community resources, and enrollees to support communication and care transitions
• Perform comprehensive, functional, crisis, and risk assessments
• Develop and implement care plans with routine updates
• Lead interdisciplinary care teams and collaborate with internal and external peers
• Oversee utilization of long-term services and supports
• Help members access housing, transportation, food assistance, and social services
• Educate members about Medicare and Medicaid benefits and available services
• Educate members and families about chronic condition management, medication adherence, preventive care, and healthy lifestyle choices
• Assist with preventive health strategies and gap closure
• Follow up after hospitalizations and significant health events to promote continuity of care and prevent readmissions
• Coordinate care with primary care physicians, specialists, healthcare providers, community organizations, state agencies, and service providers
• Advocate for enrollee needs and preferences
• Evaluate member satisfaction and monitor concerns
• Conduct regular member, provider, and community-based visits
• Report abuse, neglect, or exploitation as a mandated reporter under state law
• Adhere to NCQA and care management standards
• Perform other related duties as requested

RN Case Manager

• Develop, implement, and revise corporate-level clinical care standards, practice guidelines, the Quality Improvement Plan, and quality initiatives
• Develop policies and procedures
• Provide Medical Director operational leadership and Medical Economics Analytics
• Identify utilization management trends and take appropriate action
• Support regulatory, accreditation, and compliance functions for CMS, state, NCQA, and URAC requirements
• Provide staff training, clinical consultation, and clinical case review for members
• Participate in peer-to-peer discussions
• Provide provider education, training, data sharing, performance evaluations, and orientation
• Evaluate and investigate suspected fraud, abuse, and quality-of-care concerns
• Provide cross-coverage for other Medical Directors and/or markets as needed
• Provide prior authorization medical reviews, consultation, and clinical review services
• Conduct clinical reviews for designated CareSource members
• Handle clinical appeals
• Collaborate with market and product leaders to define market strategy
• Provide oversight and direction to assigned managers and associates
• Serve as clinical leader for physician-led post-service audits and payment integrity activities involving high-dollar claims, HACs, quality-of-care concerns, and claims requiring medical judgment
• Evaluate medical records, clinical documentation, claims data, and audit findings for medical necessity, clinical appropriateness, quality of care, and payment recovery opportunities
• Partner with Clinical Audit Nurses, Program Integrity, Claims, Quality, and Medical Economics on MCR program development, implementation, governance, and continuous improvement
• Lead the MCR operating model, Medical Director review team, clinical audit methodologies, physician review standards, and capability expansion
• Support provider engagement, audit findings, disputes, appeals, and related clinical review activities
• Perform other duties as requested

Enterprise Medical Director, Post-Service Review, Medical Claims Review

Clinical Specialist

• Complete assigned case/file reviews to ensure adherence to regulatory requirements and Standard Operating Procedures (SOPs)
• Conduct monthly inter-rater reliability monitoring of case reviews
• Identify training and development opportunities and collaborate with peers and Care Management to develop education and training
• Assist Management with reporting case reviews at aggregate and individual contributor levels
• Serve as a subject matter expert in assigned areas
• Participate in interdepartmental meetings and workgroups regarding Care Management procedures
• Provide cross-functional assistance for monitoring, accreditation and operational responsibilities
• Maintain familiarity with applicable Federal and State Requirements, including Corporate Integrity Agreement responsibilities
• Monitor regulatory changes, identify impacted areas, communicate changes and assist with implementation
• Pursue best practices and improvement opportunities for health services monitoring and accreditation
• Facilitate implementation of improvement initiatives
• Perform other job-related instructions as requested

Market Clinical Quality Specialist II

Quality Specialist

• Collaborate with department managers and leadership to evaluate opportunities for HEDIS data and process improvement
• Conduct business process and gap analyses to diagnose improvement opportunities and develop reusable solutions
• Lead improvement work teams, including team-member identification, meeting coordination and facilitation, and project management
• Support documentation of QIPs, PIPs, and other quality activities
• Train, educate, and deploy improvement tools, methods, and processes across assigned departments
• Analyze work processes to identify improvement opportunities
• Establish and implement measurement and data-collection methods with management and improvement teams
• Review and measure progress and take appropriate action
• Research best practices across industries
• Develop, evaluate, and implement survey tools
• Analyze survey data to inform improvement initiatives
• Coordinate and participate in quality improvement committee meetings; develop agendas, prepare minutes and presentations, and follow up on action items
• Communicate with upper management, peers, department staff, internal disciplines, outside agencies, and other entities to exchange information and resolve issues
• Track, compile, and report program and project metrics
• Research, gather, and analyze data to identify improvement opportunities
• Work with Maternal Child and Health Outcomes Management and Vendor Management to monitor vendor and community partner performance
• Monitor monthly, quarterly, and annual vendor reporting for timely receipt and accuracy
• Participate in workgroups and applicable committees
• Prepare reports, briefing materials, and other requested deliverables
• Perform other job-related instructions as requested

Market Quality Improvement Specialist II

Data Scientist

• Lead operationalization of AI and machine learning solutions from prototype through scalable production deployment
• Establish technical standards, design reviews, best practices, and reusable frameworks for AI, machine learning, and advanced analytics
• Design, develop, and oversee predictive modeling, machine learning, and statistical solutions using claims, EHR/EMR, laboratory, utilization management, clinical, and operational datasets
• Conduct data cleansing, feature engineering, exploratory data analysis, and derive actionable recommendations
• Design, develop, test, deploy, and govern Generative AI, Agentic AI, NLP, deep learning, and RAG solutions using MLOps and LLMOps practices
• Evaluate emerging AI technologies and recommend enterprise adoption strategies based on business value, risk, and scalability
• Ensure HIPAA/PHI compliance and collaborate with privacy, security, and compliance partners to mitigate AI risks
• Collaborate with clinical leadership, risk adjustment, care management, operations, IT, and analytics stakeholders to prioritize work, define KPIs, communicate results, tradeoffs, and roadmap progress
• Serve as an enterprise subject matter expert for AI, machine learning, and advanced analytics
• Mentor data scientists and contribute hands-on to innovative AI and machine learning capabilities
• Perform other job-related duties as requested

Data Scientist IV

AI Engineer

• Configure, test, and deploy AI-enablement applications using low-code/no-code platforms
• Develop and maintain web-based application components and user interfaces using modern front-end and back-end development frameworks
• Develop user interfaces exposing generative AI and NLP-based capabilities to business and operational teams
• Integrate AI model outputs into business workflows and existing operational platforms
• Collaborate with data engineers and data scientists to deploy AI solutions from analytical environments into production
• Develop Python and SQL logic for automation, orchestration, and system integration where low-code tools are insufficient
• Conduct application performance testing and troubleshooting to improve reliability
• Ensure solutions meet usability, accessibility, compliance, and performance standards
• Work within Agile and iterative methodologies using rapid prototyping and feedback
• Support deployment activities and incident management
• Partner with IT, analytics, and business teams to support application deployment and adoption
• Participate in application design discussions and recommend functionality, usability, and workflow integration improvements
• Perform other job-related duties as requested

Data Solutions AI Application Developer II – React, Node.js, Python, Streamlit, Flask, FastAPI, Django

• Lead the design, development, and implementation of advanced algorithms identifying claims for pre- and post-payment intervention related to potential Fraud, Waste, and Abuse
• Analyze and quantify claim payment issues and recommend mitigations for program integrity risks
• Identify trends, risks, and patterns across healthcare datasets and recommend strategic interventions
• Mentor analysts and data scientists through code reviews, analytical reviews, and best-practice recommendations
• Evaluate analytical, machine learning, and AI techniques for fraud detection, anomaly identification, and payment integrity
• Conduct outcome analyses for corporate program and payment integrity initiatives
• Lead complex data relationship analysis for payment integrity, anomaly detection, and FWA investigations
• Monitor and investigate anomalies and emerging FWA trends across the enterprise
• Collaborate with legal to generate data and analyses supporting legal proceedings
• Develop hypothesis tests and extrapolations on statistically valid samples to establish outlier behavior and potential recoupment
• Lead analytical strategies, project plans, methodologies, and investigative approaches
• Design dashboards, visualizations, and reporting solutions demonstrating model performance and program outcomes
• Develop AI-enabled and business intelligence dashboards supporting investigator workflows, fraud detection, operational monitoring, and executive decision-making
• Provide statistical validation and analysis of clinical program and intervention outcomes
• Integrate analytical solutions with enterprise systems, platforms, and operational workflows
• Present analytical findings and strategic recommendations to leadership and stakeholders
• Lead preparation and deployment of production-ready code, models, and automated decision-support solutions
• Research policy, billing guidelines, and CMS direction to develop new fraud, waste, and abuse concepts

Program Integrity Data Scientist III

Analyst

• Define clinical and payment policy requirements for configuration of clinical editing systems
• Research potential reimbursement policy claim edits, including support sourcing, data analysis, regulatory consistency, and network impact
• Research claim results to identify errors and discrepancies related to clinical edits, coding, payment policies, fee schedules, and rates
• Conduct systemic and targeted analysis to identify reimbursement errors and root causes
• Prepare, review, and obtain approval for clinical and payment policy analysis and documentation before implementation
• Provide input to UAT and conduct post-production validation
• Create written and oral communications summarizing findings and fact-based recommendations for providers, provider associations, and Health Partner Managers
• Document open issues, configuration design, and final resolutions
• Review and interpret regulatory items and deliver required updates
• Support system change policy initiatives, provide updates in payment policy meetings, and present to stakeholders
• Monitor configuration and claims SOPs for payment accuracy
• Assist in developing policies and procedures for claims processing, COB, appeals, and adjustments
• Ensure payment policies and decisions are documented and support provider education activities with the Health Partner team
• Perform other duties as requested

Payment Cycle Analyst II

• Provide monitoring, follow-up, and clinical care management to dually eligible enrollees with complex medical, behavioral, and social needs
• Engage enrollees in their homes and community settings while considering cultural and linguistic needs
• Liaise between healthcare providers, community resources, and enrollees to support communication and care transitions
• Complete comprehensive, functional, crisis, and risk assessments
• Develop and update care plans with enrollees
• Lead interdisciplinary care teams and collaborate with internal and external peers
• Oversee utilization of long-term services and supports
• Help members access housing, transportation, food assistance, and social services
• Educate members about Medicare and Medicaid benefits and available services
• Educate members and families about chronic conditions, medication adherence, preventive care, healthy lifestyles, and self-management
• Support preventive health strategies and close care gaps
• Follow up after hospitalizations and significant health events to promote continuity and prevent readmissions
• Coordinate care with primary care physicians, specialists, healthcare providers, community organizations, state agencies, and other stakeholders
• Advocate for enrollee needs and preferences
• Evaluate member satisfaction and monitor concerns
• Conduct regular member, provider, and community-based visits
• Report abuse, neglect, or exploitation as a mandated reporter under state law
• Adhere to NCQA and Care Management standards
• Perform other related duties as requested

RN Care Manager

Data Analyst

• Create complex data requests, reports, and visualizations
• Prepare written reports and oral presentations for senior management summarizing analyzed data, interpreting findings, and providing conclusions and recommendations
• Create key performance indicators (KPIs) to monitor data trends, proactively identify issues, and evaluate programs and solutions
• Work cross-functionally with multiple departments on collaborative projects
• Use internal and business partner portals and reporting capabilities
• Assist with training lower-level Data Analysts
• Develop supporting documentation for queries and reports
• Perform other job duties as requested

Pharmacy Data Analyst II

• Provide monitoring, follow-up, and clinical care management to dually eligible enrollees with complex medical, behavioral, and social care needs
• Engage enrollees in their homes and community settings to establish complex care management relationships
• Serve as liaison between healthcare providers, community resources, and enrollees
• Perform comprehensive, functional, crisis, and risk assessments
• Develop and implement care plans with enrollees and provide updates as status changes
• Lead interdisciplinary care teams and collaborate with internal and external peers
• Oversee utilization of long-term services and supports
• Assist members with housing, transportation, food assistance, and social services
• Educate members about Medicare, Medicaid, chronic conditions, medication adherence, preventive care, benefits, and available services
• Promote healthy lifestyle choices and self-management strategies
• Support preventive health strategies and gap closure
• Follow up after hospitalizations and significant health events to promote continuity of care and prevent readmissions
• Coordinate care with physicians, specialists, healthcare providers, community organizations, state agencies, and other stakeholders
• Advocate for enrollee needs and preferences
• Evaluate member satisfaction and monitor concerns
• Conduct regular member, provider, and community-based visits
• Report abuse, neglect, or exploitation as a mandated reporter
• Adhere to NCQA and Care Management standards
• Perform other job-related duties as requested

• Provide monitoring, follow-up, and clinical care management to dually eligible enrollees with complex medical, behavioral, and social care needs
• Engage enrollees in homes and community settings to establish complex care management relationships
• Liaise between healthcare providers, community resources, and enrollees to support communication and care transitions
• Perform comprehensive, functional, crisis, and risk assessments
• Develop and implement care plans with enrollees and provide updates as status changes
• Lead interdisciplinary care teams and create holistic care plans
• Oversee utilization of long-term services and supports
• Help members access housing, transportation, food assistance, and social services
• Educate members about Medicare, Medicaid, chronic-condition management, medication adherence, preventive care, and available benefits
• Promote healthy lifestyles and self-management strategies
• Support preventive-health strategies and gap closure
• Follow up after hospitalizations and significant health events to support continuity and prevent readmissions
• Coordinate care with physicians, specialists, healthcare providers, community organizations, state agencies, and other stakeholders
• Advocate for enrollee needs and preferences
• Evaluate member satisfaction and monitor concerns
• Conduct regular member, provider, and community-based visits
• Report abuse, neglect, or exploitation as a mandated reporter
• Adhere to NCQA and care-management standards
• Perform other related duties as requested

Registered Nurse (RN) Care Manager

Team Lead, Clinical Care Review

Medical Director, Post-Service Review, Medical Claims Review

RN Case Manager

Enterprise Medical Director, Post-Service Review, Medical Claims Review

Market Clinical Quality Specialist II

Market Quality Improvement Specialist II

Data Scientist IV

Data Solutions AI Application Developer II – React, Node.js, Python, Streamlit, Flask, FastAPI, Django

Program Integrity Data Scientist III

Payment Cycle Analyst II

RN Care Manager

Pharmacy Data Analyst II

RN Care Manager

RN Clinical Care Manager