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 support communication and care transitions
• Perform Comprehensive, MDS-HC or successor Functional, and Crisis and Risk Assessments
• Develop and implement care plans with enrollees and provide updates as their status changes
• Lead the interdisciplinary care team 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, benefits, chronic-condition management, medication adherence, and preventive care
• 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 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 under state law
• Adhere to NCQA and Care Management standards
• Perform other job-related duties as requested

Registered Nurse (RN) Clinical Care Manager

Operations

• Lead end-to-end enrollment operations across markets, including prospective enrollment, auto-enrollment, disenrollment, and reinstatement
• Lead enrollment operations integration for newly acquired or merging health plans, including system alignment, data migration, and process standardization
• Establish and lead an enterprise enrollment oversight framework with reconciliation methodologies, cross-system validation, and executive reporting
• Establish and execute enrollment operations strategy aligned with product growth, regulatory requirements, and market expansion
• Partner with IT on system enhancements, data governance, and integration strategies
• Manage vendor relationships and enrollment partners, ensuring SLA performance and resolving enrollment exceptions
• Drive transformation initiatives, including automation, AI-enabled reconciliation, and process optimization
• Monitor KPIs and operational metrics to identify risks, compliance gaps, trends, and improvement opportunities
• Lead, develop, and manage enrollment operations teams
• Oversee enrollment, regulatory compliance, financial, and vendor reconciliation activities
• Ensure compliance with CMS, Medicaid, and state regulations through audit readiness, audit responses, legislative monitoring, and corrective action plans
• Manage CMS 834/820 transactions, state data feeds, and reconciliation processes
• Establish and enforce enrollment policies, procedures, and internal controls
• Perform other job-related duties as requested

Director, Enrollment Operations – Duals Special Needs Enrollment Experience Required

Clinical Reviewer

• Process medical necessity reviews for appropriateness of authorization for health care services
• Assist with discharge planning activities, including DME and home health services
• Coordinate care for members and monitor delivery of healthcare services
• Complete prospective, concurrent, and retrospective reviews for acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services, and durable medical equipment
• Identify, document, communicate, and coordinate care to facilitate transitions to an appropriate level of care
• Engage with the medical director when additional clinical expertise is needed
• Maintain knowledge of state and federal regulations, State Contracts, Provider Agreements, benefits, and accreditation standards
• Identify and refer quality issues to Quality Improvement
• Identify and refer appropriate members for Care Management
• Provide guidance to non-clinical staff and support LPN clinical staff
• Attend medical advisement and State Hearing meetings as requested
• Assist the Team Leader with special projects or research as requested
• Perform other job-related duties as requested

Clinical Care Reviewer II – Inpatient MCD, Multi State LOB

• 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
• Liaise between healthcare providers, community resources, and enrollees to support communication and care transitions
• Perform Comprehensive, MDS-HC or successor Functional, Crisis, and Risk Assessments
• Develop and implement care plans with enrollees and provide updates as statuses change
• 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 and Medicaid benefits and available services
• Educate members and families about chronic-condition management, medication adherence, and preventive care
• Promote healthy lifestyle choices and self-management strategies
• Support preventive health strategies and gap closure
• Follow up after hospitalizations or significant health events to ensure continuity of care 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 within the healthcare system
• Evaluate member satisfaction and monitor concerns
• Conduct regular member, provider, and community-based visits, with travel potentially exceeding 50% of working time
• 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

General

• Act as first point of contact for new Life Services/JobConnect members
• Direct new members through the intake process
• Answer and route incoming telephone calls or initiate intake for first-time callers
• Verify and complete the intake process for each new member
• Create and maintain new member files
• Provide timely and accurate documentation
• Participate in team meetings and maintain knowledge of department activities
• Build and strengthen member relationships through quality customer service
• Maintain communication with new members after Life Services events by confirming next steps and continuing the onboarding process
• Assist in auditing member data for accuracy
• Perform data entry and basic analysis, including pulling specific reports as needed
• Manage all aspects of departmental Member Assistance Fund requests
• Assist with health education, wellness materials, and member benefits as directed
• Perform other requested job duties

Member Engagement Specialist I

Project Manager

• Manage construction, renovation, and reconfiguration projects
• Develop and track project budgets
• Oversee project work, occupancy planning, and facility operations coordination
• Manage project administration, including proposals, purchase requisitions, invoices, and facility work orders
• Develop comprehensive project work plans and schedules, incorporating IT requirements as needed
• Assist with and execute project meetings for construction and furniture reconfiguration projects
• Oversee and direct contracted vendors and contractors, monitoring schedule and quality
• Plan and lead individual moves and support re-stacking initiatives across multiple locations
• Maintain interior signage and furniture inventory programs
• Maintain design and construction standards, practices, and procedures for compliance with building codes and federal and state standards
• Maintain and communicate facility and workplace policies
• Track seating assignments and update internal systems for hires, role changes, terminations, and moves
• Coordinate furniture repairs and reconfigurations with vendors and internal resources
• Maintain electronic records, budget tracking, project finish binders, and furniture binders
• Establish and maintain a space facilitator network for space allocations and seating assignments
• Conduct ergonomic assessments as needed and collaborate with HR
• Perform other duties as requested

Facilities Project Manager III, Corporate Real Estate Experience Required

Manager

• Provide care coordination, including in-home assessment, planning, facilitation, advocacy and authorization of covered plan services
• Assess and closely monitor members’ needs and status across the healthcare continuum
• Authorize covered services and coordinate care regardless of payer
• Collaborate with members, families, caregivers, primary care practitioners and the interdisciplinary team
• Help members maintain the most independent living situation possible
• Provide continuous care management across hospital, sub-acute, long-term and home settings
• Assess ongoing eligibility for services based on plan criteria
• Perform home visits to assess living situation, cultural influences, and functional and cognitive needs
• Collaborate with physicians and the Inter-Disciplinary Team to develop Patient Centered Service Plans
• Ensure safe and appropriate member discharge plans
• Identify, investigate and document same-day grievances
• Present complex care management cases at Intensive Care Management meetings
• Respond to member requests within designated timeframes and complete Initial Adverse Determinations as indicated
• Identify members requiring Care Management Review and formulate appropriate plans of care
• Document care management and coordination according to company and plan policies
• Develop efficient plans of care and authorize needed services at appropriate levels using network providers
• Perform other related duties as requested
• Travel regularly to homes, offices and other public settings, potentially more than 50% of the time

BH Nurse Care Manager – MLTC

Director

• Shape and implement strategies that enhance members' quality of care and lead transformational change in the market
• Lead implementation of Alternative Payment Model (APM) agreements
• Ensure provider performance and engagement comply with CareSource provider agreements, ODM, and CMS requirements
• Lead development and execution of CareSource's Behavioral Health strategy
• Coordinate assessment of provider APM level and readiness
• Analyze gaps in care and advance providers along the care coordination continuum with regional teams
• Contribute to APM quality and performance programs aligned with Quality, Contracting, and Network Performance
• Oversee behavioral health provider performance and relations operations
• Participate in and lead All-Plan quality withhold and regulatory programs and initiatives
• Partner with Provider Network Performance to meet quality, performance, and financial contract specifications
• Lead development and maintenance of departmental policies and procedures
• Design and implement provider engagement strategies to improve quality, member satisfaction, population health, and healthcare costs
• Perform other job-related duties as requested

Director, Provider Performance Engagement

• Provide care coordination through in-home assessment, planning, facilitation, advocacy and authorization of covered plan services
• Assess and closely monitor members' needs and status across the healthcare continuum
• Authorize covered services and coordinate care regardless of payer
• Collaborate with members, families, caregivers, primary care practitioners and the interdisciplinary team
• Support the most independent living situation possible
• Provide continuous care management across hospital, sub-acute, long-term and home settings
• Assess ongoing eligibility for services
• Perform home visits to assess living situations, cultural influences, and functional and cognitive needs
• Collaborate with the primary care physician and Inter-Disciplinary Team to develop Patient Centered Service Plans
• Ensure safe and appropriate member discharge plans
• Identify, investigate and document same-day grievances
• Present members with complex care management needs at Intensive Care Management meetings
• Respond to member requests within designated timeframes and complete Initial Adverse Determinations as indicated
• Identify members requiring Care Management Review and formulate appropriate plans of care
• Document care management and coordination according to company and plan policies
• Develop efficient plans of care, authorize needed services at appropriate levels, utilize network providers and ensure services meet member needs
• Perform other related duties as requested
• Travel regularly to homes, offices and other public settings in a mobile position

Nurse Care Manager

• Execute the strategy, governance, delivery, and performance of Consumer Experience programs
• Recommend program direction and integrate work across business and technical functions
• Ensure regulatory requirements, consumer insights, operational initiatives, and performance-improvement activities are translated into a coordinated enterprise program
• Drive member-centric thinking by integrating the voice of the consumer into strategy, multiyear roadmaps, program development, and experience improvement initiatives
• Serve as subject-matter expert for Consumer Experience initiatives, methodologies, performance drivers, study design and administration, data structures, and industry practices
• Translate regulatory requirements, survey results and trends, consumer insights, and operational performance into enterprise strategies, investment recommendations, and measurable improvement plans
• Provide program-level guidance, mentorship, and subject-matter leadership to team members and cross-functional partners
• Lead complex, interdependent research and engagement projects across their lifecycle, aligning scope, study design, documentation, dependencies, risks, and outcomes
• Develop and present program analysis, actionable insights, and recommendations to executive sponsors, senior leaders, and governance bodies
• Influence business owners and workstream leads to secure commitments and accountability for actions, milestones, and performance outcomes
• Support operational vendor governance, including performance governance, contract deliverables, data quality, escalations, issue resolution, and service expectations
• Ensure documentation, controls, and evidence support Quality, NCQA accreditation, audit, and regulatory requirements
• Recommend priorities and corrective actions when performance, regulatory, or operational objectives are not met; implement approved actions and monitor outcomes
• Represent the team in program meetings and perform other related duties as requested

Consumer Experience Program Lead

• Provide leadership and direction to the Enrollment team
• Ensure department and CareSource goals and standards are met
• Manage staff to ensure timely, accurate, high-quality completion of service items
• Oversee financial and member enrollment reconciliation for assigned lines of business
• Oversee vendor eligibility extract processes
• Ensure compliance with regulatory requirements
• Manage enrollment technology and process analysts and activities involving 834 and DTRR file processes and departmental policies and procedures
• Manage enrollment audit engagements and develop corrective action plans as needed
• Gather, analyze, and report department performance data and recommend process improvements
• Participate in development of new products and technologies
• Manage daily operations and projects through resource allocation
• Develop and maintain knowledge of the company’s business and regulatory environments
• Incorporate change and risk management controls
• Hire, train, coach, and develop direct reports, including performance appraisals and disciplinary actions
• Mentor team leads and team members
• Perform other related duties as requested

Manager, Enrollment Operations – Health Plan Enrollment Experience Required

Strategist

• Lead assigned consumer experience projects and initiatives from planning through execution and monitoring
• Foster member-centric thinking and integrate consumer voice into strategy, roadmaps, program development and experience improvement initiatives
• Partner with external vendors for survey administration and Consumer Advisory Council activities
• Monitor and report performance for assigned initiatives, programs and workstreams
• Align programs with business strategy and the Consumer Experience strategic roadmap
• Incorporate insights from advisory councils, surveys, appeals and grievance data, Medicare complaints and customer service call logs
• Collaborate cross-functionally to design and implement strategies that improve member engagement and satisfaction
• Maintain program timelines, expenditures, deliverables and outcome metrics
• Analyze and consolidate insights to identify trends, strengths and improvement areas
• Integrate competitor, geographic and population data into enterprise and localized strategies
• Prepare and present findings and recommendations to stakeholders and senior leadership
• Integrate industry trends, innovations and best practices into the strategic roadmap
• Facilitate training and workshops on experience insights and member satisfaction
• Foster relationships with stakeholders, providers, community organizations and regulatory bodies
• Escalate material risks, dependencies, resource constraints and decisions to leadership and program governance forums
• Perform other related duties as requested

Consumer Experience Program Strategist

Medical Director

• Support staff through training, clinical consultation, and clinical case review for members
• Provide clinical review services as directed
• 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
• Participate in evaluation and investigation of suspected fraud, abuse, and quality-of-care concerns
• Participate in development of policies and procedures
• Participate in quality improvement initiatives, case management activities, and member safety activities
• Provide cross-coverage for other Medical Directors and/or markets as needed
• Oversee and support quality improvement activities associated with case management
• Review utilization data to identify pattern variances and provide feedback and education to MCP staff and providers
• Develop, implement, and revise clinical care standards and practice guidelines in compliance with nationally accepted quality standards
• Develop, implement, and revise the Quality Improvement Plan and corporate-level quality initiatives
• Collaborate with market/product leaders to help define market strategy
• Participate in community collaboratives
• Support regulatory and accreditation functions and compliance for CMS, State, NCQA, and URAC programs
• Perform other job-related duties as requested
• May work evenings/weekends
• May sit or stand for extended periods in a general office environment

Financial Planning and Analysis

• Provide financial oversight, leadership and support to the region/market/corporate
• Collaborate with departments across the organization
• Provide strategic and tactical support to region/market leaders to reach targets
• Prepare timely, accurate, comprehensive and transparent financial reporting, including operating statements, trend reports and key business reports
• Assist growth and business development opportunities in existing markets
• Evaluate premium and claims assumptions for new markets or products
• Support region/market/Senior leaders in establishing and reaching targets
• Prepare and present Monthly/Quarterly Business Review documents
• Drive favorable resolution to internal and external issues with diplomacy and sensitivity
• Understand reimbursement methodologies affecting market products
• Support monthly close through journal entries, accruals and supporting analysis
• Drive the QAI plan and coordinate initiatives to exceed targets
• Coordinate rate advocacy, revenue maximization, risk adjustment, quality initiatives and product pricing
• Prepare cost reports and regulatory filings; interact with regulatory agencies as needed
• Support annual budgeting and monthly/quarterly forecasting
• Provide insight into risk sensitivity associated with current and future business drivers
• Coordinate and support independent financial accounting and regulatory financial audits
• Perform ad hoc, trending and modeling analyses with Health Analytics
• Support market-specific contracting and enhancement initiatives
• Manage departmental staff
• Develop, implement and modify processes for efficiency and effectiveness
• Assess internal controls and make changes to ensure compliance with MAR, regulatory and organizational requirements
• Perform other duties as requested

Senior Director, Market Chief Financial Officer

Assessor

• Engage with members to establish effective, professional relationships and conduct health risk assessments
• Participate in the Integrated Care Coordination Team as needed
• Coordinate logistics supporting care plan goals and interventions to address immediate member concerns
• Verify member eligibility, previous enrollment history, demographics and current health status before outreach
• Conduct assessments by gathering information from members, families, providers and other stakeholders
• Contribute to care plan development and implementation and report assessment outcomes to the Care Coordinator when needed
• Assist with health education, wellness materials and coaching
• Maintain appropriate documentation within Care Management program protocols and guidelines
• Approach interventions by understanding each member’s perspective, unique needs and how CareSource can help
• Help members feel informed, empowered and supported by CareSource
• Improve processes to simplify members’ experience and streamline assessment and follow-up time
• Perform other job duties as requested

Registered Nurse (RN) Clinical Care Manager

Director, Enrollment Operations – Duals Special Needs Enrollment Experience Required

Clinical Care Reviewer II – Inpatient MCD, Multi State LOB

Registered Nurse (RN) Clinical Care Manager

Member Engagement Specialist I

Facilities Project Manager III, Corporate Real Estate Experience Required

BH Nurse Care Manager – MLTC

Director, Provider Performance Engagement

Nurse Care Manager

Consumer Experience Program Lead

Manager, Enrollment Operations – Health Plan Enrollment Experience Required

Consumer Experience Program Strategist

Medical Director

Senior Director, Market Chief Financial Officer

Member Health Assessor