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The Quality Analyst II is responsible for analyzing and interpreting complex healthcare data. This role will collaborate with cross-functional teams, providing analytical insight to inform strategy and interventions to drive improved quality performance. Essential Functions: Generate graphics that effectively describe, explore and summarize analyses for communication to appropriate parties Responsible for completing the analysis process to determine best course of action for each inquiry/problem Review reports and data for pattern identification, special cause variation identification, trend analysis, or other techniques and provide management level summaries that explain key findings Collaborate with team members on technical specifications and coding tactics Assist in quality dashboard development and reporting using Power BI and other visual data tools Gathers and understands requirements for analytic requests Perform any other job duties as assigned Education and Experience: Bachelor of Science/Arts degree in Management Information Systems (MIS), computer science or related field or equivalent work experience is required Minimum of two (2) year experience of HEDIS or similar quality healthcare performance metrics experience is required. 2 years Prior programming experience (i.e. SQL, SAS, Python or DAX) is required Health care delivery and/or payer experience is preferred Clinical experience is preferred Competencies, Knowledge and Skills: Proficient with Microsoft Office Suite Proficient in minimum one of the programming skills (i.e., SAS, SQL, or DAX) required Analytic skills for solving multi-dimensional business questions Graphic development & presentation skills Exposure to statistical concepts preferred Critical listening & thinking skills Effective verbal and written communication skills Problem Solving skills Knowledge of managed care and health care data coding Ability to work with IT teams, familiarity with MDS and data architecture 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 Fostering a Collaborative Workplace Culture 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 environment of belonging that welcomes and supports individuals of all backgrounds.#LI-GB1

The Care Manager plans and manages behavioral and/or physical care with members and works collaboratively with them, their supports, providers, and health care team members. The Care Manager is responsible for applying care management principles when engaging members and addressing coordination of their health care services to provide an excellent member experience, address barriers, and improve their health outcomes. The Care Manager is assigned to a specific product line such as CompleteCare, SNP, Medicaid/Medicare, PHSP, HARP, etc. Duties and Responsibilities: Advocates, informs, and educates beneficiaries on services, self-management techniques, and health benefits. Conducts assessments to identify barriers and opportunities for intervention. Develops care plans that align with the physician's treatment plans and recommends interventions that align with proposed goals. Generates referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement and maintenance of successful health outcomes. Liaise between service providers such as doctors, social workers, discharge planners, and community-based service providers to ensure care is coordinated and care needs are adequately addressed. Coordinates and facilitates with the multi-disciplinary health care team as necessary to ensure care plan goals and treatment is person-centered and maximizes member health outcomes. Assists in identifying opportunities for alternative care options based on member needs and assessments. Evaluates service authorizations to ensure alignment and execution of the member's care and physician treatment plan. Contributes to corporate goals through ongoing execution of member care plans and member goal achievement. Documents all encounters with providers, members, and vendors in the appropriate system in accordance with internal and established documentation procedures; follows up as needed; and updates care plans based on member needs, as appropriate. Occasional overtime as necessary. Additional duties as assigned. Minimum Qualifications: For Medical Care Management: NYS RN or LCSW or LMSW (any state) For PEDS positions only: 1 year of pediatric clinical field experience and/or experience with families and child serving systems, including child welfare and/or medically fragile/developmentally disabled populations For Behavioral Health (BH) Care Management: NYS RN or LCSW, LMSW, LMFT, LMHC, LPC, licensed psychologist (any state) 3 years of work experience in a mental/behavioral health or addictions setting For BH PEDS positions only: 1 year of pediatric clinical field experience and/or experience with families and child serving systems, including child welfare and/or medically fragile/developmentally disabled populations Preferred Qualifications: Strong interpersonal and assessment skills, especially the ability to relate well with seniors, their families, and community care providers, along with demonstrated ability to handle rapidly changing situations. Fluency in Fujianese Knowledge and experience with the current community health practices for the frail adult population and cognitive impaired seniors. Experience managing member information in a shared network environment using paperless database modules and archival systems. Experience and knowledge of the relevant product line Relevant work experience preferably as a Care Manager Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment Proficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systems Experience using Microsoft Excel with the ability to edit, search, sort/filter and other Microsoft and PHI systems WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to *********************** or calling ************ . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $81,099 - $116,480 All Other Locations (within approved locations): $71,594 - $106,080 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, grievances and appeals that are presented by the member or provider pertaining to the authorization of or delivery of clinical and non-clinical services. A&G works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner. The A&G Specialist is the subject matter expert responsible for non-clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The A&G Specialist will manage his/her own caseload and is accountable for investigating and resolving member or provider initiated cases. Manages all Department of Health (DOH) and executive complaints as needed. The incumbent may also handle non-clinical claim appeals that come from Healthfirst participating and non-participating providers. This is full-time on-site position located at either the 100 Church Street location in New York City or the 1101 Greenwood Avenue location, Lake Mary, Florida. This position may require attendance at A&G/ Operations divisional meetings and Town Halls, some of which may require travel to one of the locations (T&E will be covered according to policy). **This position is Remote Duties and Responsibilities Responsible for case development and resolution of non-clinical cases, such as: certain types of claim denials, member complaints, and member and provider appeals. The end-to-end process requires the Specialist to independently: Research issues Reference and understand HF's internal health plans' policies and procedures to frame decisions Interpret regulations Resolve cases and make critical decisions Edit and finalize resolution letters Manage all duties within regulatory timeframes Communicate effectively to hand-off or pick-up work from colleagues Work within a framework that measures productivity and quality for each Specialist against expectations Additional duties as assigned Minimum Qualifications Bachelor's degree from an accredited institution or relevant work experience Preferred Qualifications Minimum of two (2) years of work experience in Managed Care or Health Insurance Work experience in claims, customer service, home health, hospital or doctor's office preferred Experience working in care management systems, such as CCMS, TruCare or Hyland Demonstrated critical thinking and decision-making competencies Highly effective communication, organizational, and customer service skills Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $57,408 - $76,960 All Other Locations (within approved locations): $49,795 - $72,800 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role. WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to *********************** or calling ************ . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services. EEO Law Poster and Supplement All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $57,408 - $76,960 All Other Locations (within approved locations): $49,795 - $72,800 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

Additional Candidates must be local to installation and be licensed at the independent level as a Mental Health Counselor (LMHC), Therapist (LMFT), Social Worker (LCSW) or equivalent independent licensure. Provides the full breadth of MFLC consultation and counseling services to the command structure and military service members and their families at military installations. Responsible for providing MFLC services including non-medical, short-term, walk-around counseling, training/health and wellness presentations, and consultation to installation command regarding behavioral health issues with an understanding of the military unit, cultural and mission. Works closely with the Regional Supervisor/Regional Director, installation, and military branch Points of Contact (POC) to assure that the program is provided within scope and meets the needs of the installation. * Provides non-medical, short-term, solution focused, walk-around counseling directly to eligible service and family members at assigned primary and secondary locations. Services include assessment, brief counseling and consultation, action planning, referral to resources (assuring linkage as appropriate), and follow-up as indicated. * Delivers training and health and wellness presentations, participates in health fairs and other base/installation activities as requested/directed. * Enters counselor activity data daily through smart phone, or web application, to assure that reporting is accurate from assigned installation, while maintaining client/service member confidentiality. * Consistently visible within the brigade/regiment which allows MFLC services to be accessible. Establishes and maintains working relationships with community resources and provides appropriate linkages for service members and their families. Partners with POC to provide MFLC services in a manner that addresses the needs of the installation. Develops an effective and professional working relationship with the installation POC. * Provides MFLC response to critical incidents, surge and on demand events, and special requests as directed by the POC and approved by the Office of Secretary of Defense (OSD) program manager. Counselor will flex schedule to respond to urgent requests as needed or at the request of the Regional Supervisor/Regional Director. * Manages duty to warn and restricted reporting situations according to Department of Defense (DoD) protocol and staffs the cases with Regional Supervisor/Regional Director. * Communicates with Regional Supervisors and participates in regular individual and group supervision, sharing information regarding trends and issues on the installations to which the counselor is assigned. * Participates in regular in-services/training, Quality Improvement committees or other contract activities as assigned/appropriate. * Participates in initiatives, studies, and pilot programs as directed by the customer and/or Magellan. This includes participation in pilot program certification and training processes, completion of activity documentation, integration of pilot activities in non-medical counseling work, and the utilization of applicable technology to complete required activities. * All other duties as assigned. The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description. Other Job Requirements Responsibilities Master's degree from an accredited graduate program in a relevant field of study to include, but not limited to, a mental health related field such as social work, psychology, marriage/family therapy, or counseling. Valid unrestricted independent counseling license from a State, District of Columbia, US Territory or Commonwealth that grants authority to provide counseling services as an independent practitioner. A minimum 2 years of post-licensure clinical experience. Demonstrate intermediate-level competencies in technology and software (i.e., Microsoft Suite, Internet navigation, Smartphone/Tablet and application navigation, video-conferencing platform navigation). Requires ability to engage and communicate with military members or children as assigned, in order to accomplish job functions, and to respond quickly to emergent situations in any physical location on a military installation and/or within a school setting, which includes the need to traverse short and/or long distances within the base to both indoor and outdoor locations, to maneuver through rugged, outdoor or uneven locations (e.g., steep inclines, stairs, grass), and work in outdoor weather and other military base conditions. May require travel to locations outside of a military base installation in a variety of physical environments. Due to the nature of working on military installations or related worksites, counselors may need to comply with various site-specific requirements to work at designated locations. For example, for some assignments, counselors will need to have certain immunizations or vaccinations and provide record of receipt. Ability to prove US Citizenship and must be fluent in English. Understanding, sensitivity and empathy for service members and their families. Ability to develop trusting, helping relationships. Ability to work with individuals and families from diverse racial, ethnic, and socioeconomic backgrounds. Pass a National Agency Check and Inquiries (NACI) Clearance, an Installation Records Check (IRC), Criminal Background Check, and FBI Fingerprints Check. Vehicle Operator's License Requirement: Unless specifically waived by the FEDSIM COR, all contractor personnel providing counseling support at Government locations shall possess a valid U.S. state vehicle operator's license. As a condition for employment under this contract, contractor personnel may be required to pass all tests for and obtain a U.S. military vehicle operator's permit for commercial sedans and similar, for use at Temporary Duty (TDY) locations, if required. General Job Information Title Military and Family Life Counselor Adult, Child Youth and School Grade MFLC Tier 2 Work Experience - Required Clinical Work Experience - Preferred Education - Required Master's - Behavioral Health Education - Preferred License and Certifications - Required Current licensure required for this position that meets State, Commonwealth or customer-specific requirements - Care MgmtCare Mgmt, DL - Driver License, Valid In State - OtherOther, Must be an independently licensed behavioral health clinician - Care MgmtCare Mgmt License and Certifications - Preferred Salary Range Salary Minimum: $59,922 Salary Maximum: $100,280 This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing. Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

The Human Research Protection Specialist will assist with oversight of human research protection programs, Institutional Review Boards (IRBs), human subject protection standards, policy and procedure development, and regulatory compliance. Assists in the development and implementation of human subject protection standards, policies, procedures and systems relative to clinical research and cross-discipline human subject research, research subject protection, and institutional and investigator compliance. Serves as point-of-contact for assigned Commands and provide guidance and oversight, as needed. Provides consultation for updating regulations and policies at the component level. Assesses Command compliance with federal and institutional regulations and policies through the following tasks: Periodically reviews Command Assurances for the protection of human research subjects. Assurance reviews can include an application, Command Instructions, IRB roster, IRB Policies and Procedures, agreements with other Commands, and summaries of training for key staff. Reviews and analyzes institution-specific Management Plans, Instructions, policies, and procedures. Provide a written report for each assessment including specific findings and recommendations to further institutional compliance and/or initiate quality improvements. Conducts site inspections and assist visits with Commands on a regular basis. Coordinate with the Command staff and other site inspection or assist visit team members, including leadership, if any. Site inspections and assist visits may include: interviews with human research protection staff, interviews with researchers, review of Command research files, and review of investigator files. Evaluate and assess findings objectively and integrate all activities and results into a final Assessment report or summary. Headquarters Level Review of IRB reviewed protocols for which the Program has regulatory oversight. Provide a written report for each protocol reviewed and keep track of trends. Communicate findings to IRB staff to ensure compliance. Serve as a subject matter expert to Institutional Officials, Human Research Protections Officers (HRPOs), Institutional Review Board (IRB) members and staff, and other HRPP staff on human research protection and compliance regulations, policies, and procedures. Subject matter expertise includes knowledge of human research ethical foundations, federal regulations, requirements, GCP standards, and standards for the responsible conduct of research. Serves as site inspection or assist visit team member for other HRPP staff members, as needed. Performs full range of subject matter research and analyses. Interprets results to determine validity and significance. Prepare written reports presenting the results, interpretations, conclusions, and impact analysis. Identifies need for new processes, systems, methods or approaches, guidance documents, standards, and training needs. The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description. Other Job Requirements Responsibilities Minimum of 4 years' experience in human research protection and compliance oversight Bachelor's degree in biomedical or socio-behavioral field required. Subject matter expertise in human research protection, including application of the Common Rule and subparts B, C and D; HIPAA; and other human research protection regulatory requirements. Exceptional communication skills (verbal and written), with proven technical writing abilities (Writing sample required to be provided) . Superior analytic, problem solving, and negotiating skills. Excellent demonstrated project and time-management skills. Demonstrated success in change management. Travel to domestic and international destinations possible Travel required up to 8 times per year. Human subjects protection and regulatory compliance certification (or obtained within 6 months of hire). Must be able to work independently in Microsoft Windows 7 and Microsoft Office 2010 (Excel, Outlook, Powerpoint, Publisher, and Word). Interim Secret Clearance required to start. General Job Information Title Human Research Protection Specialist, DONHRPP, Falls Church, Virginia Grade 24 Work Experience - Required Research Work Experience - Preferred Education - Required Bachelor's Education - Preferred Master's License and Certifications - Required License and Certifications - Preferred Salary Range Salary Minimum: $58,440 Salary Maximum: $93,500 This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing. Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

This position provides non-clinical, evidence-based peer support services and serves as a member and family advocate. The FSN brings their life experiences and skills to deliver assistance to the family as they explore the goals they would like to achieve and offers interventions to the family to increase engagement and empowerment within a variety of service delivery systems. Provides peer support to family/caregivers of children with mental health and substance use conditions identified as requiring intensive wellness support and recovery-oriented interventions. Guides families in creating Wellness Recovery Action Plans (WRAP ) for themselves and their family to recognize strengths and identify wellness self-management and crisis prevention strategies. Utilizes the 8 dimensions of wellness to help parents/caregivers identify their social determinants of health needs, determine their whole health goals and objectives in order to address their own challenges and those of their child. Guides and empowers family members to understand and participate in all decisions related to the treatment process, the support plan, service choices, and transitions in care. Coaches and role-models regarding a parent's perspective and lessons learned from life experience. Facilitates support and education to families who have questions, concerns or specific needs related to mental health or substance use and their relationship to Magellan and child serving agencies. Strategically shares their lived experience to inspire hope, empowerment, and positive action. Performs ongoing interventions to engage families and members in traditional and nontraditional health services and supports, as well as community and social support networks including community-based peer, parent, and family support services. Facilitates a team approach to member care including with the Magellan care coordination team. Implements, coordinates, and monitors strategies for members and families to improve health and quality of life outcomes. Acts as an advocate for family and member`s needs by identifying and addressing gaps in services and supports. Educates providers, supporting staff, members, and families on resiliency and recovery-oriented principles, practices, strategies, and tools. Documents all interactions according to company standards. Maintains professional responsibility to maximize supervision, respond appropriately to personal stressors that impact ability to perform job duties, and recognize crisis situations or risks to the member's safety and respond appropriately. Travels to meet families within the community. Other duties as assigned. The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description. Other Job Requirements Responsibilities 2+ years' experience working as a family peer specialist. Peer Specialist certification as required by the state. CFPS/National Peer Support Credential required within one year of hire. Must be or have been a parent or caregiver of a child who is or who has in the past received services from a child-serving agency for mental health related issues. Applicants must be able to draw from their own personal experience of parenting or caregiving for a child or youth with significant mental health or substance use challenges; negotiating services and supports for their child and family; be familiar with key resources for children, youth and families in the community; be able to transcend personal events to provide unconditional support and assistance to families. Positive attitude that communicates hope and a recovery and resiliency orientation; approachable and empathetic; strong people skills. Must have a vehicle in good, working condition with the ability to travel within the community regularly. Working knowledge of Microsoft Office Product Suite. Ability to make decisions that require significant analysis of solutions, and quick, original, and independent thinking. Ability to determine appropriate courses of action in complex situations that may not be addressed by existing policies or protocols. Knowledge of local mental health, substance use, and community systems; wellness strategies, resiliency and recovery principles, practices, and tools, such as system of care, Wellness Recovery Action Plans (WRAP), wraparound process, and community-based peer, family and parent support organizations and services. Strong interpersonal and organizational skills and effective verbal and written communication skills. Ability to represent strengths and needs of families and members in clinical settings. Ability to summarize and document findings and maintain complete and accurate records. Must be able to work effectively, independently and in a team, and prioritize in a fast-paced environment to meet the demands of the organization. General Job Information Title Family Support Navigator Grade 19 Work Experience - Required Lived experience as parent/caregiver of a child with mental health challenges, Peer Specialist Work Experience - Preferred Education - Required Education - Preferred Associate License and Certifications - Required CPRS/CPS/CPSS/CRPS/PRSS, Peer Specialist, State Requirements - Care MgmtCare Mgmt, DL - Driver License, Valid In State - OtherOther License and Certifications - Preferred NCPS - National Certified Peer Specialist - Care MgmtCare Mgmt Salary Range Salary Minimum: $37,725 Salary Maximum: $56,595 This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing. Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

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 Claims department Review special projects and identify issue trends and potential resolutions Assist with Onbase reporting and processes Develop and draft P&P's and job aides for Claims Assist in training claims staff on claims processing policy and procedures Assist in educating/training Business Partners on claims functions Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data. Perform analysis of all claims data in order to provide decision support to Claims management team Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues If assigned to Research and Resolution team, responsibilities include: Represent Claims Department at requested provider calls and visits Provide feedback and/or face-to-face interaction with providers for claims research and resolution Responsible for research and resolution of claims issues for all assigned provider inquiries and submissions Responsible for managing provider issues adhering to Workflow processes and tools (Facets and Onbase) Provide input for claims business requirements, testing processes and implementation tasks and plans Perform any other job related instructions, as requested Education and Experience: Bachelor's degree or equivalent years of relevant work experience required Minimum of two (2) years of healthcare claims environment is required Competencies, Knowledge and Skills: Advanced level experience in Microsoft Word, Excel and PowerPoint Data analysis and trending skills 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 Ability to work independently and within a team environment Attention to detail Familiarity of the healthcare field Critical listening and thinking skills Negotiation skills/experience Strong interpersonal skills Proper grammar usage Technical writing skills Time management skills Strong communication skills, both written and verbal Customer service orientation 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: $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 Fostering a Collaborative Workplace Culture 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 environment of belonging that welcomes and supports individuals of all backgrounds.#LI-RW1

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 evaluation of financial experience and trend drivers Develop and communicate actionable and strategic recommendations to leadership in support of company goals Manage the development and maintenance of actuarial models to support key business goals and initiatives, such as actual to expected experience reporting, actuarial reserves and accruals, bid pricing/rate filings, forecasting, and contracting models Own the actuarial processes being managed (i.e., rate/bid filings, pricing, forecasting, reserving) within the company and with external vendors for assigned lines of business Specific function may require performing baseline analysis on expectations of rate changes for future years and work with federal and state agencies to support rate filings and other relevant activities Specific function may require overseeing development and review of Incurred But Not Reported (IBNR) reserve estimates for all CareSource lines of business on a monthly basis Perform any other job related instructions as requested Education and Experience: Bachelor's degree in actuarial science, mathematics, economics or a related field or equivalent years of relevant work experience is required Two to three (2 to 3) years or more of management experience is preferred Two to three (2 to 3) years or more of actuarial experience is preferred Strong database (SQL, SAS or Access) experience is preferred Managed care or healthcare experience is preferred Preferred: Experience leading Medicaid rate advocacy in at least one state Preferred: Understanding of accounting concepts such as accruals Competencies, Knowledge and Skills: Excellent written and verbal communication skills Excellent listening and critical thinking skills Strong interpersonal skills and high level of professionalism Ability to manage, develop, and motivate staff Ability to develop, prioritize and accomplish goals Ability to interact with all levels of management as well as external stakeholders Excellent problem-solving skills with attention to detail Excellent auditing and peer reviewing skills Ability to work independently and within a team Ability to effectively analyze data, develop/maintain appropriate models, draw and report findings and/or conclusions tailored for respective audiences Demonstrate sound business judgment when drawing conclusions and making recommendations Communicate status and results of processes, projects, goals and tasks with leader as needed or requested Expert proficiency level with Microsoft Excel Advanced proficiency with Microsoft Suite to include Word and Power Point Knowledge of SQL, SAS, R, Python or other data manipulation software Licensure and Certification: Associate of the Society of Actuaries (ASA) is required Fellow of the Society of Actuaries (FSA) is preferred Working Conditions: General office environment; may be required to sit or stand for extended periods of time May be required to travel less than 10% of the 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-RW1

The Lead Digital Product Manager drives and aligns digital product vision, strategy, and development. This role champions key digital product management initiatives that move the needle for the digital product management team and the company, and requires experience with enterprise architecture, big data technologies, product management skill set, and a roll-up-your-sleeves, entrepreneurial approach. Essential Functions: Align digital product strategy to CareSource prioritized market opportunities Translate digital product business strategies into roadmaps and manage execution of initiatives to support the overall strategy Ensure product success from ideation to launch and beyond Direct involvement in all stages of the product life cycle to foster a deep understanding of market opportunities and customer needs within the industry Deliver customer-centric experience showing proven success in ownership, bias for action, and thinking big Effectively prioritize initiatives, existing versus new customer segments and between features, architectural improvements, and operational excellence Build strong business cases, managing high-growth, successful product launches, and driving customer success Define and communicate the vision, business goals, and strategies to effectively align teams Determine metrics to measure progress and to advance team performance and product success Develop the product roadmap, working with technical stakeholders to come up with the feature distribution sequence Effectively communicate requirements, epics, and stories to ensure schedules are followed with considerations for new short-term requirements and their effects on long-term plans Constantly coordinate with business stakeholders to drive growth in the company's market share Create and develop products that not only address unmet customer needs and incorporate market trends, but products users will also love Identify and anticipate new and emerging opportunities by staying updated with trends, industry standards, and evolving market and customer needs Monitor product backlog, optimize existing processes, define new processes, and encourage best practices Lead teams through design, development, testing, and distribution of major products and features Guide and collaborate with teams through changes and iterations to be made to already distributed products Proactively identify, manage, and mitigate risks including implementing mitigation strategies and communicating/escalating to key stakeholders Leverage Human Centered Design and Design Thinking principles to facilitate putting our members and providers at the center of our work Track individual product performance by offering, market segment, etc., and recommend modifications/enhancements as needed Execute the activities required to support the development of short and long-term strategic product design plans for Product, Market, Sales, and overall growth and profitability objectives Assist in the tasks to support the established budgets, timelines (milestones) and task schedules Assist in development of reports as required by external governing bodies and internal stakeholders Perform any other job duties as requested Education and Experience: Bachelor of Arts/Science degree in Marketing, IT, Business, Communication Finance, or health care field, or other related field, or equivalent years of relevant work experience is required Minimum of ten (10) years of progressive product management, development, and/or market strategy experience is required Experience in digital strategy, digital design customer facing solutions (web, mobile) and digital/IT development processes is required Healthcare insurance industry experience is highly preferred Familiarity of the healthcare/managed care field and knowledge of government program products is preferred Competencies, Knowledge and Skills: Proficiency with Microsoft Office products Commitment to the mission and values of the CareSource Family of Companies Demonstrated technical product management skills: discovery, development, delivery, and measurement Display a customer service, Customer (Member/Provider) Obsession Ability to participate in technical evaluations and conduct research & development in emerging technologies Demonstrated strong analysis, organizational, and analytic skills Strong interpersonal skills including excellent written and verbal communication skills; listening and critical thinking; presentation skills, facilitation skills Ability to establish effective working relationships with stakeholders at all different levels Ability to effectively prioritize and execute tasks while working both independently and in a team-oriented, collaborative environment Effective planning, negotiating, and influencing skillset Ability to actively gather appropriate level of participation and input to decision-making and foster it within teams Licensure and Certification: None 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 Fostering a Collaborative Workplace Culture 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 environment of belonging that welcomes and supports individuals of all backgrounds.#LI-EM1

The UM Pharmacy Technician is responsible for the intake and review of prior authorization requests for medications requested under the medical benefit. The UM Pharmacy Technician makes approval decisions and denial recommendations based on predetermined clinical criteria. They establish rapport with Provider offices and leverages strong communication and customer service skills when providing updates and delivering decision notifications to members and providers, The UM Pharmacy Technician position is part of multidisciplinary team and works closely with Providers, Pharmacists, and Medical Directors. Duties & Responsibilities: Reviews prior authorization requests and units for medications requested under the medical benefit Assesses provider-submitted clinical information for clinical appropriateness based on predetermined clinical criteria Sends notification to members and providers of authorization decisions via telephone, fax, or mail Ensures prior authorization reviews are conducted within timeframes set forth by CMS and/or NYSDOH Establishes great rapport with Provider offices via telephonic communication Sends request for information sheets to Providers Ensures that patient information is shared appropriately maintaining confidentiality and compliance with federal law and HIPAA regulations Additional duties as necessary Minimum Qualifications: High School Diploma or GED from an accredited institution Either nationally certified Pharmacy Technician in good standing (i.e., PTCB, NHA) or registered or licensed Pharmacy Technician in good standing Experience conducting prior authorization reviews Experience requiring written, verbal, and telephonic communication in English that is clear, concise, grammatically correct, and professional Preferred Qualifications: Strong written and verbal communication skills in Chinese, Spanish, or Russian Demonstrated critical thinking and problem-solving skills Team player with a passion for learning and interest in growing skills in a dynamic environment with various opportunities Knowledge of specialty pharmaceuticals and billing practices in the medical benefit Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations PC Skills with Microsoft Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables). Experience with TruCare Care Management Platform Compliance & Regulatory Responsibilities: Noted above License/Certification: Nationally certified Pharmacy Technician in good standing (i.e., PTCB, NHA) or registered or a licensed Pharmacy Technician in good standing. WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to *********************** or calling ************ . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $47,403 - $64,338 All Other Locations (within approved locations): $41,101 - $60,320 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

The Claims Specialist III is responsible for capturing, resolving/facilitating resolution, and reporting on claim adjustment requests. Essential Functions: Resolve complex COB issues through member information updates and adjustment of claims Maintain accountability for daily tasks and goals to ensure completion of requests within requested SLA and department standards Identify potential process improvements Work with peers to ensure implementation of identified process improvements through the Plan, Do, Study, Act (PDSA) cycle with proper documentation updates and sharing of improvement with team and department Process/adjust a wide variety of claims accurately and timely following established guidelines for accuracy, quality and productivity Act as a technical resource for training, providing job shadowing, departmental communication, and coaching Ensure all assigned provider issues are resolved and communicated to the provider within appropriate timeframes and claims resolutions are coordinated with all appropriate departments in order to resolve Assist providers with inquiries including but not limited to; verifying proper medical coding, explanation of benefits, negative balance requests, claims, and appeal procedures Identify, track and trend claims payment errors in order to determine root causes and actions needed to correct problems. Work directly with Configuration, Network Operations, and Service Center through resolution of payment errors. Ensure reporting on provider inquires and complaints is compliant with current and future regulatory and accreditation bodies such as; ODJFS, MDCH, CMS, OFIR, NCQA and URAC Adhere to all HIPAA, State, and Federal requirements and regulations at all times in existing and future lines of business Perform any other job related instructions, as requested Education and Experience: High School Diploma or equivalent is required Minimum of one (1) year of experience in claims environment or related healthcare operations experience required Previous experience in an HMO or related industry preferred Previous Medicare/Medicaid dual eligible claims experience is preferred Managed Care Organization or related healthcare industry experience preferred Competencies, Knowledge and Skills: Proficient in Microsoft Office Suite, to include Word, Excel and PowerPoint Medical terminology; CPT and ICD coding knowledge strongly preferred Knowledge of medical billing practices Intermediate level data entry skills Excellent written and verbal communication skills Ability to develop, prioritize and accomplish goals Effective listening and critical thinking skills Strong interpersonal skills and a high level of professionalism Ability to coach and provide feedback effectively Effective problem solving skills with attention to detail Ability to work independently and within a team environment Licensure and Certification: None Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation Range: $40,400.00 - $64,700.00 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 Fostering a Collaborative Workplace Culture 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 environment of belonging that welcomes and supports individuals of all backgrounds.#LI-RW1

The Director, Enterprise Value Based Reimbursement (VBR) Strategy serves as the enterprise-wide VBR strategy lead to all markets and lines of business. The Director will lead ongoing engagements with market leadership to build VBR strategy plans, collaborate with state partners around VBR strategy, and coordinate VBR program solutions for markets. Essential Functions: Support the development and execution of both enterprise-level and market-specific value-based reimbursement (VBR) strategies to enhance organizational alignment and effectiveness across various markets and lines of business. Collaborative with market leadership on VBR strategies that address specific requirements for Request for Proposals (RFPs), and continue collaboration post-RFP to build and implement effective VBR program plans. Partner closely with market leadership to ensure compliance with state-level VBR requirements and commitments by leveraging appropriate strategies and programs to meet regulatory expectations. Build strong, influential, and collaborative relationships with key internal stakeholders and external partners to shape and drive VBR program strategy. Lead discussions with healthcare providers and organizations that are instrumental in fostering enterprise-wide VBR partnerships. Continuously evaluate and adjust VBR programs to ensure they remain in alignment with enterprise objectives, enhancing their impact and relevance. Oversee the development and operationalization of policies, standards, benchmarks, performance metrics, and quality control mechanisms to ensure high standards in VBR strategy execution. Maintain up-to-date knowledge of regulatory changes and market-specific performance standards to guarantee compliance and ensure timely execution. Lead negotiations and contract discussions with healthcare providers identified as providing innovative care solutions that support a comprehensive national VBR approach. Provide leadership, mentorship, and professional development opportunities to staff, fostering a supportive environment that encourages growth and excellence in performance. Perform any other job related duties as requested. Education and Experience: Bachelor's degree in management, healthcare management or related field is required Master's degree is preferred Equivalent years of relevant work experience may be accepted in lieu of required education Five (5) years of experience in value-based reimbursement design, methodologies and/or VBR contracting, data analysis, reporting, or data support is required Three (3) years of Provider contracting or Provider relations is required Five (5) years of leadership/management experience is required Competencies, Knowledge and Skills: Proficient in Microsoft Office to include Word, PowerPoint, Access - advanced proficiency in Excel Excellent team facilitation skills High level of analytic skills for solving problems Excellent oral, written, and interpersonal communication skills Strong knowledge of Value Based Contracting methodologies and operations and/or experience in health care quality Knowledge of provider contracting and familiarity with provider network operations Critical listening and thinking skills Problem solving skills Attention to detail and work plan creation, implementation, and evaluation Business acumen and strategic thinking skills, yet able to execute tactically Strong relationship management skills and ability to maintain and build strong working relationships in a matrix environment Licensure and Certification:Working Conditions: General office environment; may be required to sit or stand for extended periods of time Up to 15% (Occasional) travel to attend meetings, trainings, and conferences may be required 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 Fostering a Collaborative Workplace Culture 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 environment of belonging that welcomes and supports individuals of all backgrounds.#LI-SW2

TrueCare is a Mississippi non-profit, provider-sponsored health plan formed by a coalition of Mississippi hospitals and health systems throughout the state and supported by CareSource's national leadership in quality and operational excellence. TrueCare offers locally based provider services through provider engagement representatives and customer care. Our sole mission is to improve the health of Mississippians by leveraging local physician experience to inform decision-making, aligning incentives, using data more effectively, and reducing friction between the delivery and financing of health care. By doing so, TrueCare will change the way health care is delivered in Mississippi. Job Summary: The Configuration Systems Analyst II Leads and defines system requirements associated with Member Benefits, Provider Reimbursement and payment systems requirements definition, documentation, design, testing, training and implementation support using appropriate templates or analysis tools. Essential Functions: Identify, manage and document the status of open issues. 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, utilizing TriZetto or Optum for research and correction. Utilize available tools provided by relevant State or Federal websites to obtain pertinent Fed/State Regulatory Transmittals and Fee Schedules. Plan/implement new software releases including testing and training. Participate in meetings with business owners and users to achieve a Plan benefit design and Provider Reimbursement. Serve as liaison between IT and business areas to research requirements for IT projects, meet with decision makers to translate IT specifications and define business requirements and system goals. Lead review of benefits or provider reimbursement as well as identify and design appropriate changes. Lead in the development and execution of test plans and scenarios for all benefit or reimbursement designs and for the core business system and related processes. Provides detail analysis of efficiencies related to system enhancement/automation. Review, analyze, and document the effectiveness and efficiency of existing systems and develop strategies for improving or further leveraging these systems. Conduct preliminary studies to define needs and determine feasibility of system design. Audit configuration to ensure accuracy and tight internal controls to minimize fraud and abuse and overpayment related issues. Ensure system processes and documents exist as basis for system logic. Assists in resolution for potential business risk, including communication and escalation as necessary. Vendor management between TriZetto and CareSource. Applies use of tools to define requirements such as data modeling, use case analysis, workflow analysis and functional analysis. Perform any other job related instructions as requested Education and Experience: High School Diploma or GED is required Bachelor's Degree or equivalent years of relevant work experience is preferred Minimum of three (3) years health plan experience, to include two (2) years of configuration or clinical editing software experience is required Exposure to Facets is preferred Competencies, Knowledge and Skills: Advanced computer skills with Microsoft Word, Excel, Access, Visio and abilities in Facets 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 Critical listening and thinking skills Decision making/problem solving skills Enhanced communication skills both written and verbal Can work independently and within a team environment Attention to detail Understanding of the healthcare field Knowledge of Medicaid/Medicare Claims processing skills Proper grammar usage Time management skills Proper phone etiquette Customer service oriented Facets knowledge/training Proper claim coding knowledge Ability to be telecommuter Broad understanding of business considerations and functionality preferred 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: $63,720.00 - $101,880.00 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 Fostering a Collaborative Workplace Culture 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 environment of belonging that welcomes and supports individuals of all backgrounds.#LI-GB1

The Healthcare Analyst II is responsible for analyzing healthcare utilization and costs to identify patterns, variation, and outliers. Identify and quantify opportunities to reduce medical costs and understand their related financial outcomes. Essential Functions: Analyze healthcare utilization to identify patterns, variation, and outliers. Identify and quantify opportunities to reduce medical costs within the markets Evaluate the effectiveness of medical cost reduction initiatives. Support tracking and reporting of medical cost reduction initiatives. Work with Actuarial and Market Finance teams to accurately accrue and forecast the savings impacts of medical cost reduction initiatives. Understand the measurement of financial outcomes related to medical cost reduction initiatives. Develop tools to efficiently compare market performance across and within products. Support reporting on realized savings using sound analytical and financial techniques Work collaboratively with cross functional teams, including department leaders and operators, to understand/track operational details of medical cost reduction initiatives. Support the intake, prioritization and coordinated execution of ad-hoc analytics requests from departments across the organization Perform any other job duties as requested Education and Experience: Bachelor's Degree or equivalent years of relevant work experience is required Minimum of two (2) years of experience in healthcare analytics is required Managed care experience is strongly preferred. Experience with financial analysis is required, health plan preferred. Competencies, Knowledge and Skills: Knowledge of healthcare data, including medical and pharmacy claims, EMR data, HIE data, UM data and demographic data Knowledge of Medicaid, Medicare and other government sponsored healthcare programs is preferred Proficient in with Excel, Word and PowerPoint Proficient with Transact-SQL or SAS or Microsoft Power BI or Tableau Proficient in Financial reporting concepts Ability to organize data in a way that facilitates inferences, conclusions and decisions 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 Fostering a Collaborative Workplace Culture 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 environment of belonging that welcomes and supports individuals of all backgrounds.#LI-EM1

Internship Program The CareSource Intern is responsible for providing support on special projects, initiatives, and specific activities which will vary by assignment. We offer a 12-week, paid summer internship program for college students who want to separate themselves from the pack. This is an exciting opportunity to obtain real-world experience and prepare yourself for your career after college. The program offers: The opportunity to work on projects that truly impact the company Journey-to-the-Job seminars with CareSource leaders to network and learn about their career paths An assigned mentor and access to former interns who earned full-time positions with CareSource An opportunity to test what you have learned and discover where you want to go The satisfaction of working with smart and motivated people while building new skills What You'll Be Doing: Providing basic support for identity and access issues, including troubleshooting user account problems. Assisting with the implementation and configuration of IAM tools and software. Helping maintain user access controls and permissions. Learning about IAM best practices and security protocols. Assisting with data entry and organization related to user identities. Completing special projects as assigned. Education and Experience: High School Diploma or equivalent is required Current Rising Junior or Senior in an accredited degree program or graduated within the last 6 months is required Role: As an IAM intern, you'll focus on supporting identity and access management processes, learning about IAM operations, and developing essential skills in this critical area of cybersecurity. Expectations: Learning and Development: Demonstrate a strong desire to learn about IAM systems, user provisioning, and security measures. Basic Technical Support: Assist with troubleshooting user account issues, such as access requests and authentication problems. IAM Tool Support: Help with the implementation and configuration of IAM solutions. Data Management: Assist with data entry, organization, and maintenance of user identity records. Project Assistance: Support IAM projects as assigned, including tasks like data analysis and documentation. Professionalism: Maintain a professional demeanor, adhere to company policies, and communicate effectively. Technical Skills: IAM Tools: Gain experience with various IAM platforms and tools. Identity Management: Learn about user provisioning, access controls, and security practices. Problem-Solving: Develop critical thinking skills through troubleshooting IAM-related issues. Cybersecurity Fundamentals: Understand the basics of cybersecurity as it relates to identity and access management. Professional Development: Work Ethic: Build strong work habits and time management skills. Teamwork: Collaborate with colleagues on IAM projects and initiatives. Communication: Improve your written and verbal communication skills through interactions with team members. Professionalism: Learn the importance of professionalism in a workplace setting. Industry Exposure: IAM Department Operations: Gain insight into the daily workings of an IAM team. Technology Trends: Learn about emerging trends in identity and access management and cybersecurity. Career Paths: Explore different career paths within IAM and identify areas of interest for your future. Compensation Range: $35,200.00 - $56,200.00 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): 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-JH1

The Network Contract Specialist will be responsible for creating and maintaining behavioral health provider contracts across the New Mexico territory for Presbyterian Health Plan with Medicaid, Medicare, and Commercial lines of business. This role includes managing provider contracting activities in coordination with the Network team and processing all necessary contract-related updates. Key responsibilities include handling contract changes, Statements of Work, amendments, rate updates, Letters of Direction, and other required modifications. The specialist will also ensure all contract updates are compliant with internal policies and New Mexico-specific regulatory requirements. Strong collaboration with internal departments is essential to maintain network accuracy, provider data integrity, and overall operational efficiency. Detailed tracking and documentation of all contract activities and provider communications are critical components of this role. Support and maintain behavioral health provider contracts for Medicaid, Medicare, and Commercial lines of business across the New Mexico territory Perform provider contracting functions in collaboration with the Network team Process contract-related updates including: Exhibits Contract changes SOS Amendments Rate updates Letters of Direction (LODs) NCQA/CAQH Ensure compliance with internal standards and state-specific requirements Collaborate with internal departments to support network accuracy, provider data integrity, and operational efficiency Maintain thorough documentation and tracking of all contract activity and communications This position is responsible for the support of all activities related to developing and maintaining the physician, practitioner, group, and/or facility, MPPS and organization services delivery system in small to mid-size market defined by membership, number of providers in delivery system, number of business operating units and lines of business. Interacts with all areas of organization to coordinate network management and network administration responsibilities. Assesses network needs, analyzes network composition, and using organization databases, application of regulatory requirements, accreditation entities and other resources, recruits individual, group and/or organizational providers to meet network adequacy standards and assure quality network. Conducts and coordinates contracting and amendment initiatives. Provides issue resolution and complex trouble shooting for providers. Conducts provider education and provider relation activities, providing necessary written materials. Conducts administrative provider site visits and coordinates report development and completion according to contractual requirements or ad hoc requests. Coordinates Public Policy Research Center (PPRC) activities to assure maintenance of current credentialing status, and evaluation and appropriate actions of quality of care issues and complaints against providers. Conducts and manages ongoing audits of provider compliance with Magellan policies and procedures as well as contractual obligations for multiple customers. Develops work plans to address audit requirements. Works with management to draft, clarify and recommend changes to policies which impact network management. The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description. Other Job Requirements Responsibilities Knowledge of National Committee for Quality Assurance (NCQA) requirements. Ability to work independently and prioritize activities. Intermediate knowledge of Microsoft Office Suite, specifically Excel. Strong presentations skills using PowerPoint. Minimum of 1 year experience in related position/field. General Job Information Title Network Management Specialist (Contract Specialist) Grade 21 Work Experience - Required Network Work Experience - Preferred Education - Required Education - Preferred Bachelor's License and Certifications - Required License and Certifications - Preferred Salary Range Salary Minimum: $45,655 Salary Maximum: $68,485 This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing. Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

The Internal Auditor II works in a self-directed team environment to execute internal audits as defined by management and the Audit Committee with progressive latitude for team goal setting, initiative and independent judgement on collective work products. The auditor works to identify and evaluate organizational risk, recommends and monitors mitigation action and supports the development of the annual audit plan. Essential Functions: Conduct operational, performance, financial and/or compliance audit project work including, business process survey, project planning, risk determination, test work, recommendation development and monitoring and validation of remediation Work within a self-directed team environment with limited direct supervision, employing significant creativity in determining efficient and effective ways to achieve audit objectives Actively participate in the development and implementation of a flexible risk-based, flexible annual audit plan considering control concerns identified by senior management Coordinate and collaborate on internal audit projects including assessing the adequacy of the control environment to achieve defined objectives in accordance with the approved audit program and professional standards Facilitate communication of organizational risks and audit results to business owners through written reports and oral presentations and provide support and guidance to organizational leadership on effective internal control design and risk mitigation Coordinate, monitor, and complete team tasks within agreed upon timeframes and meet individual and team project timelines, which may be aggressive at times. Influences team prioritization and scheduling of work, problem solving, assignment of tasks, and takes initiative when problems arise. Provides cross-training of team members Support management in onboarding new team members through mentorship, shadowing, and training of all required functions and processes and influence standards for expected team behaviors Assist in the coordination of external audits of CareSource by government agencies, accounting firms, etc. Develop and maintain productive professional relationships with CareSource staff and management by developing trust and credibility Significant interaction with others in the Department of differing skillsets (clinical, IT, etc.), organizational management and staff throughout CareSource, including interaction with the senior most levels Coordinate audit projects as necessary with other CareSource functions, including CareSource Assurance teams Generally conform to IIA standards and maintain all organizational and professional ethical standards, even in difficult or challenging situations Willing to accept feedback, coaching and criticism from others, including peers and management both in Internal Audit or outside of Internal Audit, reflect on the information, and adapt when appropriate Perform any other job duties as requested Education and Experience: Bachelor's degree in finance, business management, healthcare administration, accounting or related field or equivalent years of relevant work experience is required Master of Business Administration (MBA), or other graduate degree is preferred A minimum of three (3) years of finance, business management, healthcare administration, accounting or related field is required; experience in internal auditing or public accounting is preferred Knowledge of audit principles and IIA Standards and Code of Ethics required Experience in risk and control assessments is preferred Experience in thoroughly documenting process flows and controls in financial, and/or business operations cycles preferred Experience with Sarbanes Oxley 404 or Model Audit Rule preferred Experience in health care or insurance fields is preferred Competencies, Knowledge and Skills: Strong communication skills, including proper writing skills adaptable for the audience and purpose, presentation skills for internal or external audiences and senior management, and interpersonal skills sufficient to develop strong professional relationships with CareSource management and staff Solid critical thinking skills including professional skepticism and problem resolution Data analysis and trending skills and ability to compose and present reports using audit data Ability to work in a matrix environment with responsibility for multiple deliverables for multiple functional areas within CareSource Team and customer service oriented Collaborative mindset and ability to operate in a self-directed team environment with collective accountability Strong ability to adapt to changing environment Strong self-leadership, organizational and time management skills Driven to proactively seek relevant development, education and training opportunities Strong sense of integrity and ethics in performance of all duties Takes initiative to identify and influence innovative process improvement Self-driven to work independently within a team environment Success in working in a self-directed matrixed environment Advanced level experience in Microsoft products Licensure and Certification: CIA, CISA, CPA, CMA, CRMA or other appropriate finance, IT or internal audit licensure or certification is preferred Working Conditions: Most work will be performed in an office or virtual setting; however, performing onsite audits may also be necessary depending on assignments May be required to sit or stand for extended periods 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 Fostering a Collaborative Workplace Culture 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 environment of belonging that welcomes and supports individuals of all backgrounds.#LI-RW1

Independently coordinates care of individual clients with application to identified populations using assessment, care planning, implementations, coordination, monitoring and evaluation for cost effective and quality outcomes. Duties performed are either during face-to-face home visits or facility based depending on the assignment. Promotes the appropriate use of clinical and financial resources in order to improve the quality of care and member satisfaction. Assists with orientation and mentoring of new team members as appropriate. May act as a team lead for non-licensed care coordinators. Provides care coordination to members with behavioral health conditions identified and assessed as requiring intensive interventions and oversight including multiple, clinical, social and community resources. Conducts in depth health risk assessment and/or comprehensive needs assessment which includes, but is not limited to psycho-social, physical, medical, behavioral, environmental, and financial parameters. Communicates and develops the care plan and serves as point of contact to ensure services are rendered appropriately (e.g., during transition to home care, back up plans, community based services). Implements, coordinates, and monitors strategies for members and families to improve health and quality of life outcomes. Develops, documents and implements plan which provides appropriate resources to address social, physical, mental, emotional, spiritual and supportive needs. Acts as an advocate for members' care needs by identifying and addressing gaps in care. Performs ongoing monitoring of the plan of care to evaluate effectiveness. Measures the effectiveness of interventions as identified in the members care plan. Assesses and reviews plan of care regularly to identify gaps in care, trends to improve health and quality of life outcomes. Collects clinical path variance data that indicates potential areas for improvement of case and services provided. Works with members and the interdisciplinary care plan team to adjust plan of care, when necessary. Educates providers, supporting staff, members and families regarding care coordination role and health strategies with a focus on member-focused approach to care. Facilitates a team approach to the coordination and cost effective delivery to quality care and services. Facilitates a team approach, including the Interdisciplinary Care Plan team, to ensure appropriate interventions, cost effective delivery of quality care and services across the continuum. Collaborates with the interdisciplinary care plan team which may include member, caregivers, member`s legal representative, physician, care providers, and ancillary support services to address care issues, specific member needs and disease processes whether, medical, behavioral, social, community based or long term care services. Utilizes licensed care coordination staff as appropriate for complex cases. Provides assistance to members with questions and concerns regarding care, providers or delivery system. Maintains professional relationship with external stakeholders, such as inpatient, outpatient and community resources. Generates reports in accordance with care coordination goals. Other Job Requirements Responsibilities Associate's Degree in Nursing required for RNs, or Master's Degree in Social Work or Healthcare-related field, with an independent license, for Social Workers. Licensed in State that Services are performed and meets Magellan Credentialing criteria. 2+ years' post-licensure clinical experience. Experience in utilization management, quality assurance, home or facility care, community health, long term care or occupational health required. Experience in analyzing trends based on decision support systems. Business management skills to include, but not limited to, cost/benefit analysis, negotiation, and cost containment. Knowledge of referral coordination to community and private/public resources. Requires detailed knowledge of cost-effective coordination of care in terms of what and how work is to be done as well as why it is done, this level include interpretation of data. Ability to make decisions that require significant analysis and investigation with solutions requiring significant original thinking. Ability to determine appropriate courses of action in more complex situations that may not be addressed by existing policies or protocols. Decisions include such matters as changing in staffing levels, order in which work is done, and application of established procedures. Ability to establish strong working relationships with clinicians, hospital officials and service agency contacts. Computer literacy desired. Ability to maintain complete and accurate enrollee records. Effective verbal and written communication skills. General Job Information Title CISC Care Coordinator, Licensed Grade 24 Work Experience - Required Clinical Work Experience - Preferred Education - Required Associate - Nursing, Master's - Social Work Education - Preferred License and Certifications - Required DL - Driver License, Valid In State - Other, LISW - Licensed Independent Social Worker - Care Mgmt, LMHC - Licensed Mental Health Counselor - Care Mgmt, LMSW - Licensed Master Social Worker - Care Mgmt, LPCC - Licensed Professional Clinical Counselor - Care Mgmt, LPN - Licensed Practical Nurse - Care Mgmt, PSY - Psychologist - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt License and Certifications - Preferred Salary Range Salary Minimum: $58,440 Salary Maximum: $93,500 This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing. Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

Responsible for the development, strategy, and implementation of community outreach programs in conjunction with the Clinical and Administrative departments. Leads the development of strategic plans for engagement, within assigned territories, regions or communities, that nurture and retain positive relationships between the health plan, members and caregivers, the community, and provider organizations. Leads resource assessments within assigned region to identify potential partnerships to serve our members through enhanced access, improved community awareness of programs, and participation with established community advisory boards. Provides information about health care services, preventative care, as well as information related to health, welfare, and social services or social assistance programs offered by the state or local communities. Organizes and attends community events and health fairs. Serves as the liaison to community organizations. Conducts member, community, and organizational trainings. Completes face-to-face outreach. Ensures compliance with all state and federal marketing requirements. Drives engagement in care by facilitating a robust engagement strategy, which may include leveraging community relationships and developing opportunities to present and educate in front of members, caregivers, and other interested parties. Develops and implements promotional plans for new outreach opportunities. Distributes educational materials to community and provider organizations. Presents the program and offerings in group settings. Consistently achieves member engagement strategies while meeting quality performance standards. Attends provider and community meetings and participates in special projects. Conducts consumer and community surveys as needed. Provides training on programs to staff and agencies as necessary. Collaborates with multiple departments, including peers, business development, marketing, network contracting, and provider liaison teams. Participates as a member of the Clinical team in developing and implementing strategies to engage stakeholders. Develops and implements promotional plan for new outreach opportunities. Maintains thorough knowledge of healthcare programs and community resources. May act as a subject expert on Medicaid programs and benefits for internal and external stakeholders. Develops a resource guide for assigned territory (such as community-based organizations, service agencies, housing, food pantries, churches etc.), and cultivates relationships and identifies potential collaboration opportunities. Plans and implements territory monthly action plan and consistently meets and/or exceeds outreach targets. Produces summary reports on outreach activities. Participates in cross functional teams and quality improvement initiatives. Responsible for identifying, developing and maintaining strategic relationships with community contacts and organizations to pursue outreach engagements for multiple regions. Distributes written material to community and provider organizations. May schedule and facilitate marketing events, both formal and informal, with stakeholders that meets contract requirements. Identifies and attends community and health events. Identifies and coordinates outreach activities and necessary materials at community and health events. Organizes staff and other resources in the participation and the support of select community events and activities. Responsible for post-event follow up and maintenance of relationships for future and recurring events. Other Job Requirements Responsibilities 5+ years of community outreach and engagement experience with 1 year working with government-sponsored population, particularly Medicare and Medicaid. Self-starter with the ability to work with limited supervision. Excellent verbal and written communication skills. Must exhibit sensitivity towards the target population. 2+ years of experience working with individuals with adverse childhood experiences. General Job Information Title CISC Member, Caregiver and Stakeholder Engagement Manager Grade 23 Work Experience - Required Community Relations/Outreach Work Experience - Preferred Education - Required Associate Education - Preferred Bachelor's, Master's License and Certifications - Required DL - Driver License, Valid In State - Other License and Certifications - Preferred CPRS/CPS/CPSS/CRPS/PRSS, Peer Specialist, State Requirements - Care Mgmt, LMSW - Licensed Master Social Worker - Care Mgmt Salary Range Salary Minimum: $53,125 Salary Maximum: $84,995 This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing. Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.