Jobs at CareSource

Community-based Registered Nurse responsible for complex care management of dually-eligible enrollees. Conduct in-home and community assessments, develop and implement care plans, coordinate with providers and community resources, lead interdisciplinary teams, assist with long-term supports and benefits navigation, provide education, perform post-hospital follow-up, and ensure adherence to NCQA and care management standards. Frequent travel within assigned Massachusetts territory required.

Leads health plan enrollment operations, managing staff, enrollment and financial reconciliation, eligibility file processing, audits, regulatory compliance, enrollment technology, and process improvement. Oversees Facets and 834/DTRR activities, coordinates with vendors and IT, analyzes performance data, manages risk and corrective actions, and develops team members. Requires knowledge of Medicaid, Medicare, Dual coverage, HIPAA enrollment transactions, and health plan regulatory requirements.

Analyzes healthcare encounter and claims data, resolves data and process issues, supports CMS and state regulatory submissions, monitors SLAs and performance metrics, and contributes to testing, reporting, automation, and process improvement. The role collaborates with IT, claims, enrollment, vendors, and regulatory stakeholders while ensuring compliant encounter reconciliation and accurate claims data.

Develop and deploy AI-enabled applications, web interfaces, and workflow integrations using low-code platforms and modern programming frameworks. Build Python and SQL automation, integrate generative AI and NLP capabilities, collaborate with data and business teams, and support testing, troubleshooting, Agile delivery, deployment, and incident management. Ensure solutions meet usability, accessibility, compliance, and performance standards.

Leads advanced data science and machine learning initiatives for healthcare payment integrity, including fraud, waste, and abuse detection, anomaly identification, predictive modeling, statistical analysis, dashboards, and recovery investigations. Provides technical leadership, mentors analysts, integrates production analytical solutions, collaborates with legal and business stakeholders, and presents findings to leadership. Requires healthcare expertise, advanced SQL and programming skills, and knowledge of claims, billing, reimbursement, and program integrity.

Provides analytical support for healthcare claims payment policies, clinical edits, reimbursement analysis, regulatory updates, configuration changes, UAT, and post-production validation. Researches payment discrepancies, identifies root causes, documents policy decisions, monitors claims processing accuracy, and communicates findings to providers and internal stakeholders. Requires health plan or provider coding and payment policy experience, strong knowledge of healthcare coding systems, claims operations, managed care, Medicare, Medicaid, and CMS guidelines.

Leads enterprise enrollment operations across healthcare product lines, overseeing enrollment lifecycle activities, system integrations, data integrity, reconciliations, vendors, regulatory compliance, audits, and process transformation. Partners with IT and external agencies, manages CMS and Medicaid transactions, establishes operational controls and reporting frameworks, and develops high-performing teams. Requires extensive leadership experience and expertise in Medicaid managed care, Medicare Advantage, or Dual Special Needs Plans.

Designs, validates, and operationalizes predictive, machine learning, and artificial intelligence models using large structured and unstructured datasets. Performs statistical analysis, feature engineering, exploratory analysis, visualization, and clinical program outcome validation. Collaborates cross-functionally to integrate solutions, prepares end-to-end model pipelines, and communicates analytical findings to stakeholders to improve business processes.

Develop complex healthcare reports, ETL solutions, databases, and Power BI dashboards for LTSS and Dual Eligible programs. Analyze multidimensional data, ensure governance and accuracy, identify operational improvements, and deliver actionable insights to leadership. The role translates business requirements into scalable reporting solutions, collaborates with clinical, operational, data engineering, and IT teams, and leads testing, process automation, visualization, and large cross-functional data projects.

Directs market-specific healthcare quality improvement programs, ensuring compliance with NCQA and state requirements. Oversees quality plans, performance improvement projects, audits, corrective actions, data analysis, risk assessment, reporting, committees, and regulatory initiatives. Partners with enterprise stakeholders, represents the organization externally, supports budgeting and strategic planning, and leads quality outcomes for Medicaid or managed care markets.

Leads enterprise business analysis strategy across multiple programs and portfolios. Partners with executives on business cases, investment decisions, requirements, prioritization, risks, value realization, and transformation initiatives. Establishes governance, methodologies, standards, and performance measures while guiding complex requirements efforts. Analyzes operational and financial data, supports payer regulatory compliance, drives AI and automation adoption, and mentors business analysts and project teams.

Provides administrative support to the Market President and office, including preparing presentations, correspondence, reports, calendars, meetings, travel arrangements, expense reports, and meeting minutes. Serves as an office gatekeeper and coordinates facilities, shipping, equipment, visitor badges, and market events. Requires discretion, confidentiality, strong communication, organization, problem-solving, and Microsoft Office proficiency.

Lead a small actuarial team responsible for pricing, forecasting, reserving, and actuarial modeling for supplemental benefits. Develop assumptions, evaluate experience and trends, support rate filings and IBNR reserve estimates, provide strategic recommendations, and ensure compliance with actuarial standards.

Lead the actuarial function to drive pricing, forecasting, rate filings, and financial analysis. Develop statistical models, ensure regulatory compliance, mentor staff, support senior management and business development, and implement AI-enabled solutions to improve efficiency and insights.