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Position Purpose: The Program Manager IV leads the planning and delivery of transformational enterprise initiatives focused on optimizing healthcare operations and processes. Leading matrixed operations teams to deliver programs, ensuring operational readiness and alignment of systems, process, inte

Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate

Position Purpose: Perform various analysis and interpretation to link business needs and objectives for assigned function. This position supports the accuracy, consistency, and regulatory readiness of provider-directory information by analyzing, mapping, validating, and reconciling data across multi

Position Purpose: This role, sitting within the Integrated Communication Services (ICS) Center of Excellence, utilizes business expertise to facilitate, lead and drive complex large-scale work efforts across domains and/or large-scale cross-functional initiatives with matrixed team support. Analyzes

Position Purpose: Create, review, and approve home modification requests managing all aspects of the process while ensuring waiver and contract requirements are met. Key details: Candidates must live in Ohio within one of the following counties: Cuyahoga, Lorain, Medina, Summit, Henry, Wood, Lucas,

Position Purpose: Perform various analysis and interpretation to link business needs and objectives for assigned function. Key Details: Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not avail

Position Purpose: Supports care management activities and the teams assigned to members to ensure services are delivered by the healthcare providers and partners and continuity of care/member satisfaction is achieved. Interacts with members by performing member outreach telephonically or through hom

Position Purpose: Supports the prior authorization request to ensure all authorization requests are addressed properly and in the contractual timeline. Aids utilization management team to document authorization requests and obtain accurate and timely documentation for services related to the members

Position Purpose: Provides on-site and remote technical support to end users and site IT infrastructure (including network, print, audio/video and office setup) by troubleshooting hardware and software problems. Analyzes events and applies technical knowledge following established procedures and sta

Position Purpose: Provides on-site and remote technical support to end users and site IT infrastructure (including network, print, audio/video and office setup) by troubleshooting hardware and software problems. Analyzes events and applies technical knowledge following established procedures and sta

Position Purpose: Performs care management duties to assess and coordinate all aspects of medical and supporting services across the continuum of care for complex/high acuity populations with primary medical/physical health needs to promote quality, cost effective care. Develops a personalized care

Position Purpose: Directs the gathering and organization of assessment data and results to support risk reporting and monitoring processes. Advises, designs, and/or validates the status of IT controls and processes and assists in the design of corrective actions to address control deficiencies. Key

Position Purpose: The Business Solutions Developer III is responsible for designing, developing, implementing, and supporting business-managed applications, automations, data solutions, and reporting capabilities that address complex operational needs. This position serves as a technical subject mat

Position Purpose: The Manager, Business Insights leads workforce capacity planning and staffing forecast initiatives that support operational performance and enterprise objectives. This role develops and manages staffing models using historical volume, membership forecasts, productivity, processing

Position Purpose: Assesses, plans, and implements complex care management activities based on member activities to enable quality, cost-effective healthcare outcomes. Develops a personalized care plan / service plan for care members, addresses issues, and educates members and their families/care giv

Position Purpose: Supports care management activities and the teams assigned to members to ensure services are delivered by the healthcare providers and partners and continuity of care/member satisfaction is achieved. Interacts with members by performing member outreach telephonically or through hom

Position Purpose: Independently leads complex fraud, waste, and abuse (FWA) investigations involving providers, members, pharmacies, vendors, and other entities. Utilizes advanced investigative techniques, data analysis, and case development strategies to identify potential misconduct, support corre

Position Purpose: Assists in developing, assessing, and coordinating holistic care management activities to enable quality, cost-effective healthcare outcomes. May develop or assist with developing personalized service care plans/service plans for long-term care members and educates members and thei

Postition Purpose: Manages a team responsible for facilitation and leading external audits related to Risk Adjustment processes. Ensures visibility by way of reporting out audit deliverables and associated risk related for each audit. Collaborates with business areas to ensure effective prevention,

Position Purpose: Ensure timely processing of pending medical claims. Verify and update information on the submitted claims. Review work processes to determine reimbursement eligibility. Ensure payments and/or denials are made in accordance with company protocols and procedures. Job Details: Must be