CareSource Careers

Internal Auditor (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: Perform professional internal auditing work. Work involves conducting performance, operational, financial and/or compliance audit projects; providing consulting services to the organization’s management and staff; and providing input to development of the annual internal audit plan. Maintain all organizational and professional ethical standards. Work under limited supervision with moderate latitude for initiative and independent judgment. Essential Functions: • Assist in identifying and evaluating the organization’s audit risk areas and provide input to the development of the risk-based annual internal audit plan. • Perform audit procedures, including identifying and defining issues, developing criteria, reviewing and analyzing evidence, and documenting client processes and procedures. • Conduct interviews, review documents, develop and administer surveys, compose summary memos, and prepare working papers. • Identify, develop, and document audit issues and recommendations for improvement using independent judgment concerning areas being reviewed. • Communicate or assist in communicating the results of audit and consulting projects via written reports and oral presentations on a timely basis to management. • Develop and maintain productive team-oriented client and staff relationships through individual contacts and group meetings. • Pursue professional development opportunities, including external and internal training and professional association memberships, and share information gained with co-workers. • Represent internal auditing on organizational project teams and at management meetings. • Execute internal audits as defined by the Director of Internal Audit and the Audit Committee. • Document and test risks and controls inherent in the Financial Statement processes/cycles (e.g., Expenditures/AP cycle, Revenue/AR cycle, etc.) • Perform any other job related instructions as requested, with reasonable accommodation.

Reporting & Analysis Lead (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: Develop complex reporting products that meet the information needs of the organization as well as external partners. Work with the business areas to identify and implement opportunities for process improvement that impact performance, quality, and/or profit through the delivery of business intelligence and/or reporting products. Assist in the design of Business Intelligence products for both internal and external use.

Essential Functions:

Develop complex automated reporting products that meet the internal and external information needs of the organization.
Assist in the design of Business Intelligence products for both internal and external use.
Participate in testing activities as needed.
Responsible for adhering to proper coding standards and IT change control process.
Generate graphics that effectively describe, explore and summarize information for communication to appropriate parties.
Incorporate critical thinking skills and judgment in the process to determine best course of action for each inquiry/problem.
Investigation of data that shows a pattern or indicates a significant variation from expected.
Represents the department in project meetings and other meetings that require subject matter knowledge and input.
Assist the manager in directing and coordinating work within the department.
Perform any other job related instructions as requested, with reasonable accommodation.

Sr. Database Administrator (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: Analyze new and existing computer systems to determine the effectiveness of their processing methods and procedures. Recommends implementation, enhancements, and operational policy guidelines as appropriate. Essential Functions: � Design, implement, and normalize DBA structures � Defines, creates, organizes, maintains logical, physical, and production DBA�s to include physical changes. � Prepare test data and tests program performance necessary to determine that program/system performs according to design specifications and end use requirements. � Develops and maintains system end user documentation necessary to ensure effective end user operations and IT support. 1. Establishes and maintains data security, including data backup/recovery and disaster planning. � Assigns user access levels as authorized by Senior Management. � Develop logical data models and program interfaces for applications systems. � Ensures that adequate and appropriate security features are installed in all Client computer systems necessary to protect the information resources of the Client from inappropriate access and dissemination. 2. Lead service support activities and initiatives � Initiate and lead support activities including problem analysis, technical evaluation, work estimates, and implementation services. � Coordinate support or project activities with all applicable constituents including customers using the systems, IT staff supporting the systems, vendors/third parties, and/or business managers. � Identify and lead, as assigned, resources and communications to facilitate work completion. 3. Provide technical guidance, training, and work direction to less experienced system engineers � Demonstrate technical proficiency in development and implementation of medium and complex systems and/or computing infrastructure through ability to guide others. � Strong learning competency and ability to teach others. � Advanced troubleshooting and problem solving capabilities 4. Assist other IT team members in understanding policies, operating procedures, and responsibilities � Mentor and train new IT team members to assist them in orientation to policies, procedures, and responsibilities. � Provide ongoing mentorship and support for questions, problems, and ideas. � Serve as an escalation point for system engineers to escalate problems and inquiries requiring further evaluation beyond the associated skill level. 5. Establish and maintain professional working relationships between IT and its customers and constituents. � Represent IT in project and/or business meeting and engagements. � Lead conference calls or visits with vendors/third parties. � Introduce new customers to IT services to assist in familiarizing them with appropriate systems, services, policies, and procedures.

Database Administrator (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: Support and Implement existing and new database systems to assure that the quality and efficiency of the systems meet the requirements of the company. Essential Functions: � Develop, document assigned database implementation, enhancement, and operational policy guidelines � Implement, and normalize database systems � Define, create, organize, maintain logical, physical, and production databases � Execute test data and test program performance necessary to assure program/system performance according to design specifications and end user requirements � Maintain system end user documentation necessary to ensure effective end user operations and IT support � Technical proficiency in the development and implementation of medium complex database systems 1. Establish and maintain data security, confidentiality and integrity � Maintain database backup/recovery standards � Maintain database disaster recovery plans and processes � Maintain, review, update database security standards � Analyze database application security settings and recommend changes to improve security configurations � Assign user access levels as authorized 2. Participate in service support activities and initiatives � Initiate support activities including problem analysis, technical evaluation, work estimates, and implementation services � Participate in support activities with all applicable constituents including customers, IT staff, vendors/third parties, and business managers � Understand the interdependencies of all applicable constituents necessary to complete support activities � Identify resources and communications to facilitate work completion 3. Provide technical guidance, training, and work direction to less experienced team members � Develop logical data models and program interfaces for applications systems � Intermediate troubleshooting and problem solving capabilities � Keep current on technologies through self-directed learning 4. Assist other team members in understanding policies, operating procedures, and responsibilities � Train new team members � Assist team members with the orientation to policies, procedures, and responsibilities � Provide support for questions, problems, and ideas � Serve as an escalation point for less senior team members for problems and inquiries requiring further evaluation beyond the associated skill level 5. Establish and maintain professional working relationships between IT and its customers and constituents. � Participate in project and/or business meeting and engagements � Participate in conference calls or visits with vendors/third parties � Introduce new customers to IT services to assist in familiarizing them with appropriate systems, services, policies, and procedures

Regulatory Reporting Lead (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: Responsible for analysis and reporting associated with regulatory and special projects. Ensures deadlines are met and work is complete and accurate. Identify opportunities for process improvement that impact performance measures and/or regulatory compliance. Use professional concepts and knowledge of company processes and regulatory guidelines to solve a wide range of difficult problems in imaginative and practical ways.

Essential Functions:

Perform analysis associated with regulatory performance measures
Assist in the review and response of all regulatory notifications that involve DSI departments
Ensure issues associated with regulatory efforts and special projects are identified, tracked, and reported to manager in a timely manner
Lead regulatory efforts on an as needed basis
Analyze and quantify critical issues and provide recommendations, along with risks and issues involved with each alternative
Maintain knowledge of current regulatory environment and assist in research of regulatory issues and requirements
Incorporate critical thinking skills and judgment in the process to determine best course of action for each inquiry/problem
Represents the department in project meetings and other meetings that require subject matter knowledge and input
Assist the manager in directing and coordinating work within the department
Perform any other job related instructions as requested, with reasonable accommodation.

Claims Specialist (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: Coordinate with a core group of priority provider offices to identify claim problems and correct them in a timely manner. To maintain a healthy and happy relationship between CareSource and Providers. Essential Functions: � Adjust, correct and release claims for priority providers. � Research claims that may not be in the system for providers. � Converse with providers on a daily basis regarding claims and their status. � Pull documentation for providers that reference claims. � Enter hardcopy claims for provider groups. � Perform any other job related instructions as requested, with reasonable accommodation.

Medical Coding Specialist (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: Responsible for reviewing and evaluating medical record documentation for claims and/or appeals to ensure that diagnostic and procedural codes accurately reflect and support the visit as it related to correct coding guidelines and medical necessity ensuring that the data comply with legal standards and guidelines. Work collaboratively with Medical Management and the Medical Director to determine appropriate level of care.

Essential Functions:

Responsible for maintaining incoming pended claims, electronic inquiries and medical records work queue.
Prepare claims for medical director review by completing worksheets and attaching all pertinent medical information.
Read and interpret medical procedures and terminology by reviewing medical notes.
Analyze and make a determination of appropriate reimbursement for unlisted and by report codes submitted on claims.
Maintain an understanding of Federal and State Regulatory requirements, i.e. CMS, ODJFS & MDCH.
Responsible for meeting CareSource and associated Department standards for timeliness of review claims while maintaining accuracy of medical decisions. Timeliness of reviews must be consistent with regulatory standards for production and turnaround.
Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, state and departmental confidentiality guidelines.
Perform any other job related instructions as requested, with reasonable accommodation

VP Finance (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: The VP of Financial Accounting serves as the principal controller for all CareSource entities with leadership and oversight of financial accounting, financial reporting, tax management, financial planning, budgeting, forecasting, modeling, analyses, internal controls, and policies and procedures ensuring compliance with generally accepted accounting principles, statutory requirements and emerging Model Audit Rule requirements in a timely, accurate, transparent and comprehensive manner.

Essential Functions:

Provides status of financial condition of the company by collecting, interpreting and reporting key financial data and analyses, immediately alerting executive management of any identified reporting and control issues that arise.
Works with Executive and Senior Management to develop, implement, report, and continually improve the planning, budgeting, forecasting, modeling and analyses activities for the Company.
Supports the strategic planning process by providing long-term financial projections and identifying corresponding risks and opportunities.

Ensures financial stewardship for CareSource’s entities by establishing, monitoring and enforcing financial policies and procedures and internal controls. Includes leadership for ensuring the integrity and security of the general ledger and reporting system.
Provides timely, accurate comprehensive and transparent financial reporting including, but not limited to, operating statements, balance sheets, cash flow statements, and key business reports as required in accordance with generally accepted accounting principles and statutory requirements.
Oversees the annual operating and capital budgeting process
Oversees preparation of all pertinent tax reports and filings in a timely and accurate manner. Minimizes CareSource’s tax liabilities while maintaining full compliance with local, state and federal tax statutes. Leadership responsibility for managing internal capabilities with retained third-party tax experts.

Oversees preparation of provider and contract analyses; both standardized reports and as requested in a timely and accurate manner to support business decisions.
Proactively researches existing and new legislation, changes in financial accounting standards, tax statutes, and NAIC statutory requirements. Advises management of actions and potential risks.
Prepares for and timely supports all financial audits (external and internal) as required and appropriate.
Hires, trains, develops and appraises staff effectively, ensuring a strong, competent and talented team of high integrity finance professionals.
Performs any other job related instructions as requested, with reasonable accommodation.

Manager Regulatory Data Submissions (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: Responsible for maintaining scope and daily management of Regulatory Data Analysis projects and selected staff. Coordinates activities associated with regulatory and special projects. Ensures deadlines are met and work is complete and accurate. Works with DSI leadership and Corporate Compliance staff to understand and prioritize regulatory data submission requirements. Coordinate with other DSI and IT teams to identify and implement opportunities for process improvement that impact performance measures and/or regulatory compliance. Use professional concepts and knowledge of company processes and regulatory guidelines to solve a wide range of difficult problems in imaginative and practical ways.

Essential Functions:

Responsible for submission of all encounter data to state and Federal agencies.
Responsible for other data submissions to regulatory organizations as required, e.g., CAMS.
Provide guidance for staff as they work through the complex regulatory requirements.
Conceive and develop design for regulatory reporting products.
Review and provide formal response to all regulatory notifications that involve DSI departments.
Ensure issues associated with regulatory efforts and special projects are identified, tracked, and reported to leadership in a timely manner.
Lead special projects on an as needed basis.
Investigate critical issues and provides recommendations, along with risks and issues involved with each alternative.
Maintain knowledge of current regulatory environment and assist in research of regulatory issues and requirements.
Serve a liaison for other DSI departments for regulatory data requirements.
Serve on committees and project teams as needed.
Incorporate critical thinking skills and judgment in the process to determine best course of action for each inquiry/problem.
Perform any other job related instructions as requested, with reasonable accommodation.

Informatics Lead (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: Under the support and guidance of the Director of Informatics, the Senior Informatics Analyst is responsible for developing, implementing, managing, and presenting in-depth analyses that meet the health care information needs of the organization such as utilization cost analyses, care management return-on-investment analyses, performance comparisons, and state mandated measurement requirements.

Identify trends and patterns using standard departmental reports and databases as well as leveraging other processes and data sources. Conduct outcomes analyses to determine impact and effectiveness of corporate initiatives. Gather requirements from various internal and external business customers in order to understand specific analytic needs. Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data. Use professional concepts and knowledge of company policies and procedures to solve a wide range of difficult problems in imaginative and practical ways.

Essential Functions:

Conduct examination and explanation of complex data relationships to answer questions identified either within the department or by other departments.
Generate graphics that effectively describe, explore and summarize analysis for communication to appropriate parties.
Incorporate critical thinking skills and judgment in 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 that will reveal intelligence for identification of any associative or causal relationships and provide management level summaries that explain key findings.
Use statistical techniques to measure impact of various actions/studies, internal and external, develop sampling and hypothesis testing to help the organization determine outcomes, and forecast and predict future behaviors and events.
Represents the department in project meetings and other meetings that require subject matter knowledge and input
Assist the manager in directing and coordinating work within the department
Perform any other job related instructions as requested, with reasonable accommodation.

Patient Navigator - Cincinnati Area - Clermont, Brown, Adams, Pike - South Region (OH, Various)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: The Patient Navigator provides one-on-one guidance, support, education, referrals, coordination of care, and other assistance to patients as they move through the healthcare continuum as directed by the CareSource RN Case Manager. Serving as a member of the CareSource Care Coordination Center’s Team*, the patient navigator is accountable for collaborating with other members of the CareSource Care Coordination Center’s Team and contributing to the implementation of the member’s care plan. This position is a collaborative team role and will be responsible for assessments, treatment plans and evaluation of high-risk members. Regularly review a member’s utilization rate, inpatient and emergency room history, HEDIS metrics and gaps in care.

Essential Functions:

1. Guide patients through the healthcare system by assisting with access to healthcare as directed by the CareSource RN Case Manager:

1. Accompanying patients to appointments and other social service encounters when necessary
2. Coordinating logistics for plan adherence – reminders, transportation, and childcare arrangements
3. Ensuring that medication adherence issues are addressed by ongoing reporting of issues to the CareSource RN Case Manager
4. Supporting patient family members

2. Participate in the implementation of comprehensive care plans:

1. Working with CareSource members in various community, care delivery and administrative settings
2. Developing relationships with community providers and resources
3. Managing resources through interdisciplinary collaboration to achieve optimal patient outcomes
4. Demonstrating effective communication skills with all stakeholders (e.g., members, team members, community providers and resources)
Maintain knowledge and understanding of business:
1. Providing timely and accurate documentation
2. Actively participating in team meetings
3. Developing and maintaining knowledge of the company’s business and regulatory environments
Travel:

1. Travel within the community and conduct face-to-face meetings with high-risk members, treatment plan personnel, providers and community leaders
2. Abide by the CareSource’s travel policy

Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

Mobile Worker: Will work at different office locations established by CareSource and will typically work in established geographical area in the community; may

Manager Informatics (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: The Manager will oversee the operation of the department to ensure it aligns with the business objectives of the company. The Manager is also responsible for creating, scoping, planning, prioritizing and management of all informatics projects and staff. This person must work with key business units to establish and meet their analytic needs.

The Manager will also work as an analyst for Management of the organization. In this capacity the Manager will explore, research and validate various ideas for studies that could identify reductions in health care costs or delivery of higher quality services to our members. This includes the extensive use of predictive techniques to forecast trends and patterns of care. These ideas will then result in informatics team efforts to explore the validity of the concept.

This Manager, in working with the Director of Business Intelligence, locate opportunities to create visibility for CareSource though public forums or publication regarding the delivery of high quality, insightful analytics that reveal unique insights to our membership or the healthcare delivery system where CareSource conducts business.

Essential Functions:

Responsible for directing the creation, scoping, planning, prioritizing and managing of Informatics. This includes working with key business owners to establish and meet their analytic needs or the analytic needs of the organization.
Serve as informatics consultant for members of the CareSource management team.
Responsible for the execution of the efforts conducted by the Informatics team as they conduct in-depth analysis such as provider practice patterns, examination of complex data relationships, and use of statistical techniques to measure impact of various actions/results.
Serve as a DSI management liaison on analytic needs of the organization including key operational and management committees.
Responsible for the evaluation of appropriate predictive solutions throughout the organization and, as needed, assist the Director, BI Services with the deployment of those solutions into the organizations workflow.
Execute the various outcome/predictive/analytic studies that establish CareSource as a leader in analytics regarding the healthcare status, needs or delivery results of our membership. These efforts would identify trends and variances and identify in-depth cause-effect relationship between seemingly unrelated components, culminating in some public publication and/or presentation of the findings.
Working with the Director, BI Services, drive the creation of unique graphics that effectively describe, explore and summarize analysis for communication to appropriate parties.
Perform any other job related instructions as r

Regulatory Data Submission Analyst (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: The Regulatory Data Submission Analyst provides assistance and analysis related to all regulatory data submissions by CareSource to state and federal agencies of claims and case management data. This includes adhering to the various state and federal requirements regarding these submissions and working with Finance and various operational units to assure CareSource has the appropriate data submitted as accurately as possible with minimal rejections. The Analyst may also be required to work with application and database developers to maintain all components of the encounter and case management programs. Responsibilities also include researching and documenting data requirements for these regulatory data submissions.

Essential Functions:

Assist with all regulatory data submissions to state and federal agencies on a timely basis, ensuring the quality of the data submitted meets, at a minimum, the various regulatory requirements.
Monitor and address regulatory data that is either rejected by the agencies or delayed by CareSource prior to submission.
Work with Finance and various operational business owners to assure accuracy of submitted regulatory data and the working of exceptions to submissions that require additional input prior to the data being accepted.
Develop and maintain detailed documentation that provides traceability for all regulatory data.
Analyze data associated with regulatory data submissions to identifying anomalies and locate potential causes.
All other duties as assigned.

Associate Benefits Analyst (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: The Associate Benefits Analyst coordinates the implementation and administration of CareSource’s employee benefits programs consistent with the company’s overall strategic plans and objectives. A focus on servicing customer needs in a confidential and timely fashion is critical.

Essential Functions:

Benefit Administration
- Assist with the administration of health and welfare plans (such as health, dental, vision, disability, and life)
- Assist with 401k administration such as coordinating rollovers and hardship withdrawals in conjunction with the recordkeeper
- Support new hire orientation by participating in presentations to new hires
- Maintain accurate benefit files and records
Benefit Enrollment
- Facilitate the open enrollment process by collaborating on the communication strategy and roll out of benefits
- Collaborate with external resources and across departments to receive and evaluate quotes and plan design options
- Assist with the processing of life events and new hires
- Facilitate verification of dependents for benefit purposes
Disability and leave management
- Support disability and leave management by coordinating with employees, insurance providers, and across departments as needed
Policies
- Ensure the execution of administrative policies and amendments governing employee benefit plans that are in compliance with state and federal regulations
- Ensure policy documentation is created, accurate, and followed
- Counsel employees and managers on policies, procedures and benefit offerings by providing accurate and legal information that acts in the best interest of the company
Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

Working primarily in an office setting
Required to use general office equipment, such as a telephone, photocopier, fax machine, computer

Manager Medical Coder (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: Responsible for oversight and management of individuals reviewing and evaluating medical record documentation for claims and/or appeals to ensure that diagnostic and procedural codes accurately reflect and support the visit as it related to correct coding guidelines and medical necessity ensuring that the data comply with legal standards and guidelines. Work collaboratively with Medical Management and the Medical Director to determine appropriate level of care. Reviews bulletins, newsletters, and periodicals, and attends workshops to stay abreast of current issues, trends, and changes in the laws and regulations governing medical record coding and documentation; develops and updates procedures manuals to maintain standards for correct coding, minimize the risk of fraud and abuse.

Essential Functions:

Prioritize all work/request/activities. Escalate to Director areas of significant resource contention along with recommendations for resolutions.
Track issues and their status to ensure proper follow-up and coordination of issues with business area.
Develop and maintain policies, procedures surrounding Medical Coding and Clinical Edits.
Ensure that supporting business processes and documentation exists as a basis for system logic.
Assist with system upgrades and installation of vendor-supplied fixes and other programming changes.
Troubleshoot problems with system design and/or functionality and facilitate with vendor for research and correction.
Maintain and support projects and/or company initiatives.
Audit system configuration to ensure accuracy and internal controls are in place to minimize potential fraud and abuse and any business issues.
Provide expertise in regards to the code editing and software which, requires knowledge of CCI and extensive coding knowledge to uphold or adjust CareSource edit logic.
Document code editing solutions, testing and promotion of changes following the established departmental change management process.
Maintain an understanding of Federal and State Regulatory requirements, i.e. CMS, ODJFS & MDCH.
Responsible for the department meeting CareSource and associated Department standards for timeliness of review claims while maintaining accuracy of medical decisions. Timeliness of reviews must be consistent with regulatory standards for production and turnaround.
Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, state and departmental confidentiality guidelines.
Perform any other job related instructions as requested, with reasonable accommodation

Member & Provider Appeals-Grievance Coordinator (OH, Dayton)

Fri, 03 Feb 2012 17:00:00 GMT

Job Summary: The Appeals/Grievance Coordinator will research appeals/grievances for Medicaid, Medicare, and future lines of business, to determine the validity of the appeal/grievance. The Appeals/Grievance Coordinator will track, trend, and report appeals/grievances related to existing and future lines of business. Essential Functions: „X Log all appeals/grievances upon receipt in Facets. „X Stamping and sorting of incoming mail and directing or assigning as appropriate. „X Route appeals to appropriate clinical personnel after documenting Facets. „X Identify, sort, and deliver logged appeals/grievances for processing. „X Print and mail letters on denied appeals. „X Providing support to the department, including filing, printing and copying, including the preparation of new case files and State hearing case files. „X Report monthly key statistics for all lines of business to the management team. „X Perform any other job related duties as requested, with reasonable accommodations. „X Adhere to all policies and procedures, and ensure all guidelines set by regulatory bodies are followed and met. „X Other duties as assigned.

RN Case Manager - High Risk - North East Ohio Area (OH, Cleveland)

Tue, 31 Jan 2012 00:00:00 GMT

Looking for RN's located in the following counties: ***Ashtabula, Trumbull, Mahoning, Carroll, Jefferson, Lake, Portage ***

Job Summary: Coordinate the care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. Coordinate quarterly face-to-face interviews with each high-risk member. This position is a collaborative team role and will be responsible for conducting assessments, treatment plans and evaluation of high-risk members.

Essential Functions:

1. Coordination of Member Care:

a. Serves as member’s accountable point of contact

b. Verify eligibility, previous enrollment history, demographics and current health status of each member

c. Complete assessments by gathering information from the member, family, provider and other stakeholders

d. Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties

e. Monitor and evaluate care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

f. Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders

g. Responsible for team coordination and member outcomes

2. Oversight:

a. Oversee (point of contact) the care planning and execution of meeting member needs

b. Arrange and coordinate services with community partners to maximize utilization of appropriate community resources and support groups

3. Documentation, Accreditation Requirements:

a. Maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b. Maintain appropriate documentation within protocols and guidelines of the Care Management program

4. Collaboration/Building Relationships:

a. Participate in meetings with providers to inform them of Care Management services and benefits available to members

5. Education/Training:

a. Assist in education of member/caregiver regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials

b. Precept and/or mentor new staff

6. Perfor

RN Patient Care Coordinator - Team Leader (OH, Dayton)

Tue, 31 Jan 2012 00:00:00 GMT

Job Summary: Oversee day-to-day workflow issues with PCC team. Develop plan for management of workload after analyzing trends and act as advocate for PCC team. Responsible for utilization review, discharge planning activities for CareSource/CCM members and monitoring the appropriate delivery of healthcare services in a cost-effective manner. Essential Functions: • Provide guidance, orientation, training and resource to PCC and pre-auth team in day-to-day medical management team. • Standardize activity and outcome reporting for the medical management department initiatives and programs including documentation required by the State and accrediting bodies. • Responsible for utilization review, discharge planning activities for CareSource members and monitoring appropriate delivery of healthcare services in cost-effective manner. • Oversee day-to-day workflow issues within the PCC team and develop plan for management of workload. • Assist manager and director in development of process improvement activities, refining of medical management processes that facilitate cost-effective utilization and appropriate levels of care. • Act as a liaison between Case Management, Claims, Enrollment and Customer Service areas to assist in problem resolutions. • Perform audits of PCC team members to assure compliance with CareSource processes, ODJFS regulations, NCQA utilization review guidelines and standards, and URAC review guidelines. • Provide input into PCC Team evaluations and assist with development of team goals. • Design and present UM informational meetings as needed. • Responsible for attending State hearings as necessary. • Perform any other job related instructions as requested, with reasonable accommodation.

RN Bridge To Home Patient Care Coordinator (OH, Dayton)

Tue, 31 Jan 2012 00:00:00 GMT

Job Summary: Responsible for utilization review and discharge planning activities for members enrolled with a CareSource Management Group (CareSource) line of business, monitoring the appropriate delivery of health care services in a cost effective manner. Maintain knowledge of State and Federal regulations governing CareSource, State Contracts and Provider Agreement, benefits and URAC Standards. Essential Functions: • Prospective, retrospective and concurrent review of inpatient admissions, outpatient procedures, homecare services and durable medical equipment. • Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner. • Identify and refer quality issues to Quality Improvement. • Identify and refer appropriate members for Case Management. • Document and communicate with CareSource and Provider Case Managers and Discharge Planners to establish discharge planning needs and coordinate care. • Perform any other job related instructions as requested, with reasonable accommodation. • Provide direction to non-clinical medical management staff. • RN’s - Provide direction to and assist with oversight of LPN, LISW medical management staff.

Quality Analyst I (OH, Dayton)

Mon, 30 Jan 2012 00:00:00 GMT

Job Summary: Provide performance feedback and coaching to call center associates and train associates to improve interactions with members and providers. Also ensures adherence and accurate communications of all company/departmental policies and procedures.

Essential Functions:

Monitor and score recorded and live calls in accordance with company policies and procedures.
Provide analytical feedback and progressive training to Service Center Representatives to encourage developmental opportunities for performance improvement.
Review call intakes for quality and accuracy, identify trends, and prepare departmental performance reports for management.
Works closely with the Service Center Management team to ensure accurate and timely communication to Service Center Representatives.
Assist the Team Leads and senior staff as needed with daily floor management.
Perform any other job related instructions as requested, with reasonable accommodation.

Customer Service Rep III (OH, Dayton)

Mon, 30 Jan 2012 00:00:00 GMT

Job Summary: A Customer Service Representative III acts as subject matter expert, while staffing the assist line and accurately responding to inquires presented by a CSR I and II who is servicing Medicaid/Medicare member or provider, including members and providers associated with future lines of business. The CSR III also monitors queue performance, makes necessary staffing adjustments to the queues during peak periods, tracks call trends, and alerts management when necessary. Essential Functions: • Monitor and manage call queues to ensure all Customer Service Representatives are available and appropriately staffed. • Act as a “New Hire Coach” for new employees. • Maintain Outage log and report to management team weekly. • Provide Peer to Peer feedback (daily phone interaction). • Identify training needs for Service Center Representatives. • Manage and process internal route boxes. • Ability to service both member and provider calls in all lines of business, existing and future. • Utilize self-education opportunities to stay abreast of procedural updates – maintain Subject Matter Expert (SME) status in all skill sets. • Act as a mentor to new hire employees. • Answer second level assist questions. • Willingness and ability to assist Customer Service Representatives with questions and inquires. • Document all second level support questions by utilizing and maintaining the Assist Line Tracking Database. • Handle and resolve escalated member and provider complaints. • Act as a role model to other Customer Service Representatives and employees. • Display a positive attitude. • Be helpful and approachable to other Customer Service Representatives and employees. • Be accountable for actions. • Motivate other Customer Service Representatives and employees. • Assist members with routine servicing inquires including but not limited to; selecting a primary care physician, member benefit education, member identification cards, transportation arrangements, issues with provider accessibility, eligibility inquires, member complaints, identifying and filing member grievances. • Assist providers with routine servicing inquires including but not limited to; verifying eligibility, explanation of benefits, claims and appeal procedures. • Ensuring all HIPAA and State requirements/regulations are adhered too at all times in existing and future lines of business. • Research, follow up and resolve all open/pending issues in a timely manner to ensure member satisfaction. • Build and strengthen member relationships by providing quality customer service. • Maintain knowledge and understanding of all processes and procedures. • Adhere to all policies and procedures. • Maintain complete and accurate documentation of all of telephone and written communications. • Screen members to determine if they need Case Management a

Manager Care Management- High Risk - Cleveland Area - North Region (OH, Cleveland)

Mon, 30 Jan 2012 00:00:00 GMT

Job Summary: Assist the High Risk Care Management Team in coordinating care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. May conduct and/or participate in the quarterly face-to-face interviews with each high-risk member. Member of the collaborative team and may provide input to the assessments, treatment plans and evaluation of high-risk members. Actively oversee the performance of the High Risk Care Management teams to ensure all state and accreditation requirements are achieved. Constantly monitor staff performance for quality measures, workloads and productivity outcomes.

Essential Functions:

1. Coordination of Member Care:

a. Verify eligibility, previous enrollment history, demographics and current health status of each member as appropriate

b. May complete or contribute to assessments by gathering information from the member, family, provider and other stakeholders

c. May contribute to the development and implementation of the care plan, defining specific issues, goals and interventions as agreed to by all parties

d. May assist in monitoring and evaluation of care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

e. May assist in the facilitation and coordination of services based upon the care treatment plan developed in collaboration with all stakeholders

f. Responsible for overall team coordination and member outcomes.

2. Oversight:

a. Oversee the care planning and execution of meeting member needs

b. May assist in arranging and coordinating services with community partners to maximize utilization of appropriate community resources and support groups

c. Monitoring of scheduling/work allocation

d. Provides quality monitoring and conducts regularly scheduled one-on-one meetings with all team members

e. Monitor and analyze High Risk Care Management data and reporting

3. Documentation, Accreditation Requirements:

a. Oversee and/or maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b. Oversee and/or maintain appropriate documentation within protocols and guidelines of the Care Management program

c. Actively oversee the performance of the High Risk

Manager Care Management- High Risk - Columbus Area - Central Region (OH, Columbus)

Mon, 30 Jan 2012 00:00:00 GMT

Essential Functions:

1. Coordination of Member Care:

a. Verify eligibility, previous enrollment history, demographics and current health status of each member as appropriate

b. May complete or contribute to assessments by gathering information from the member, family, provider and other stakeholders

c. May contribute to the development and implementation of the care plan, defining specific issues, goals and interventions as agreed to by all parties

e. May assist in the facilitation and coordination of services based upon the care treatment plan developed in collaboration with all stakeholders

f. Responsible for overall team coordination and member outcomes.

2. Oversight:

a. Oversee the care planning and execution of meeting member needs

b. May assist in arranging and coordinating services with community partners to maximize utilization of appropriate community resources and support groups

c. Monitoring of scheduling/work allocation

d. Provides quality monitoring and conducts regularly scheduled one-on-one meetings with all team members

e. Monitor and analyze High Risk Care Management data and reporting

3. Documentation, Accreditation Requirements:

a. Oversee and/or maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b. Oversee and/or maintain appropriate documentation within protocols and guidelines of the Care Management program

c. Actively oversee the performance of the High Risk

Software Quality Analyst (OH, Dayton)

Fri, 27 Jan 2012 00:00:00 GMT

Job Summary: This position will work with team members, developers and department managers to develop, maintain, implement and execute a quality assurance process. The role is responsible to develop routine tests, and coordinate the testing efforts for all assigned applications and code base. Essential Functions: � Complete business analysis � Manage the requirements gathering process � Obtain and document business and system requirements � Document workflows � Provide requirements to development teams and participate in collaborative design sessions � Create and document test cases for all documented requirements � Manage and execute testing for all test cases: types include integration, certification, user acceptance, system, regression, and load tests. � Monitor, measure, and report metrics based on the results of all tests � Measure, Evaluate and test new or modified software programs and software development procedures used to verify that programs function according to user requirements and conform to established guidelines � Write, revise, and verify quality standards and test procedures for program design and product evaluation in order to economically and efficiently attain a high quality of software � Follow established quality assurance practices � Follow defined quality methods � Abide by quality controls and documentation procedures � Develop and maintain test plans, manual and automated test scripts for user interface, functionality, system and "ad-hoc testing" � Execute regression tests, functional tests and data tests � Report, track and determine priority of reported bugs promoting quality achievement and performance improvement � Maintain awareness of the business context of software � Ensure compliance with local, state, national and international standards and legislation � Define quality procedures in conjunction with operating staff � Collate and analyze performance data and charts against defined parameters � Ensure tests and procedures are properly understood, carried out and evaluated and that product modifications are investigated if necessary � Write technical and management systems reports � Monitor performance by gathering relevant data and producing statistical reports � Conduct tests on computer software programs to make sure the programs perform properly and are easy to use � Complete tests to determine weaknesses in software code � Review new or modified software, including documentation, diagram, and flow chart, to determine if a program will perform according to user requests and standards and conform to guidelines � Recommend program improvements or corrections to programmers � Identify program processing errors � Implement automated test programs to ascertain the validity of results, accuracy, reliability, and conformance to established standards � Identify differences between established standards and user applications and suggest modifications to conform to standards

Clinical Appeals Nurse (OH, Dayton)

Fri, 27 Jan 2012 00:00:00 GMT

Job Summary: Responsible for the completion of clinical appeals and state hearings from all states. Collaborate with the Quality Improvement, Clinical Operations Team Lead to prepare all requests for Independent External Review. Complete all responsibilities ensuring compliance with all Federal, State, and Accreditation requirements. Essential Functions: • Review and complete all provider clinical appeals within required timeframes • Review and complete member clinical appeals within required timeframes • Review all information necessary to prepare State Hearing packets • Communicate with state agencies and internal departments to prepare for State Hearings • Attend assigned State Hearings and complete all required compliances. • Complete required compliances for Administrative Hearing decisions. • Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals • Issue notification letters to providers and members • Issue administrative denials appropriately • Refer denials based on medical necessity to medical director • Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates • Conduct monthly, quarterly and ad hoc appeals reporting • Collaborate with the Quality Improvement, Clinical Operations Team Lead to prepare all requests for Independent External Review • Ensure compliance with regulatory and accrediting requirement • Perform any other job related instructions as requested, with reasonable accommodation

RN Team Lead II CM - High Risk - Clermont, Adams, Fayette, Jackson - South Region (OH, Various)

Fri, 27 Jan 2012 00:00:00 GMT

Job Summary: Under the direction of the manager, provide day-to-day direction and supervision of staff assigned to the High Risk Care Management program. Provide support, direction and assistance to CM staff. Give effective and timely feedback to staff in regards to performance outcomes and progress toward goals. Assist the High Risk Care Management Team in coordinating care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. May conduct and/or participate in the quarterly face-to-face interviews with each high-risk member. Member of the collaborative team and may provide input to the assessments, treatment plans and evaluation of high-risk members. Complete all responsibilities ensuring compliance with all Federal, State, and Accreditation requirements.

Essential Functions:

1. Coordination of Member Care:

a. Verify eligibility, previous enrollment history, demographics and current health status of each member as appropriate.

b. May complete or contribute to assessments by gathering information from the member, family, provider and other stakeholders

c. May contribute to the development and implementation of the care plan, defining specific issues, goals and interventions as agreed to by all parties

e. May assist in the facilitation and coordination of services based upon the care treatment plan developed in collaboration with all stakeholders

f. Responsible for overall team coordination and member outcomes.

2. Oversight:

a. Oversee the care planning and execution of meeting member needs

b. May assist in arranging and coordinating services with community partners to maximize utilization of appropriate community resources and support groups

c. Monitoring of scheduling/work allocation

d. Provides quality monitoring and conducts regularly scheduled one-on-one meetings with all team members

3. Documentation, Accreditation Requirements:

a. Oversee and/or maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b. Oversee and/or maintain appropriate documentation within protocols and guidelines of the Care Man

RN Team Lead II CM - High Risk - Hamilton County - South Region (OH, Various)

Fri, 27 Jan 2012 00:00:00 GMT

Essential Functions:

1. Coordination of Member Care:

a. Verify eligibility, previous enrollment history, demographics and current health status of each member as appropriate.

b. May complete or contribute to assessments by gathering information from the member, family, provider and other stakeholders

c. May contribute to the development and implementation of the care plan, defining specific issues, goals and interventions as agreed to by all parties

e. May assist in the facilitation and coordination of services based upon the care treatment plan developed in collaboration with all stakeholders

f. Responsible for overall team coordination and member outcomes.

2. Oversight:

a. Oversee the care planning and execution of meeting member needs

b. May assist in arranging and coordinating services with community partners to maximize utilization of appropriate community resources and support groups

c. Monitoring of scheduling/work allocation

d. Provides quality monitoring and conducts regularly scheduled one-on-one meetings with all team members

3. Documentation, Accreditation Requirements:

a. Oversee and/or maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b. Oversee and/or maintain appropriate documentation within protocols and guidelines of the Care Man

RN Team Lead II CM - High Risk - Scioto, Gallia, Lawrence - South Region (OH, Various)

Fri, 27 Jan 2012 00:00:00 GMT

Essential Functions:

1. Coordination of Member Care:

a. Verify eligibility, previous enrollment history, demographics and current health status of each member as appropriate.

b. May complete or contribute to assessments by gathering information from the member, family, provider and other stakeholders

c. May contribute to the development and implementation of the care plan, defining specific issues, goals and interventions as agreed to by all parties

e. May assist in the facilitation and coordination of services based upon the care treatment plan developed in collaboration with all stakeholders

f. Responsible for overall team coordination and member outcomes.

2. Oversight:

a. Oversee the care planning and execution of meeting member needs

b. May assist in arranging and coordinating services with community partners to maximize utilization of appropriate community resources and support groups

c. Monitoring of scheduling/work allocation

d. Provides quality monitoring and conducts regularly scheduled one-on-one meetings with all team members

3. Documentation, Accreditation Requirements:

a. Oversee and/or maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b. Oversee and/or maintain appropriate documentation within protocols and guidelines of the Care Man

Pharmacy Service Representative III (OH, Dayton)

Wed, 25 Jan 2012 00:00:00 GMT

Job Summary: A Pharmacy Customer Service Representative III acts as subject matter expert, while staffing the pharmacy assist line and accurately responding to inquires presented by a CSR I and II who is servicing a Medicaid/Medicare member or provider, including members and providers associated with future lines of business. The PCSR III also monitors queue performance, makes necessary staffing adjustments to the queues during peak periods, tracks call trends, and alerts management when necessary.

Essential Functions:

Receive, monitor and manage pharmacy assist queue to ensure queue is appropriately staffed.
Identify training needs for Customer Service Representatives and report findings monthly.
Conduct monthly side by sides with members of the team to identify opportunities for improvement.
Manage and process internal email and route boxes.
Utilize self-education opportunities to stay abreast of procedural updates – maintain Subject Matter Expert (SME) status in all skill sets.

· Willingness and ability to assist Customer Service Representatives with questions and inquires about the pharmacy benefit.

Document all second level support questions in facets.
Handle and resolve escalated member complaints.
Act as a role model-display a positive attitude, display a willingness to assist, be helpful, approachable and accountable for actions.
Motivate and coach employees to meet and exceed established performance metrics.
Assist members with routine pharmacy inquires .
Ensuring all HIPAA and State requirements/regulations are adhered to at all times in existing and future lines of business.
Research, follow up and resolve all open/pending issues in a timely manner to ensure member/provider satisfaction.
Build and strengthen member relationships by providing quality customer service.
Maintain knowledge and understanding of all pharmacy processes, policies and procedures and ensure adherence.
Maintain complete and accurate documentation of all of telephone and written communications.

· Route calls to appropriate departments including Grievance and Appeals and Pharmacy for proper /expedited resolution.

Assist with non phone work such as incoming faxes and web inquires.
Perform any other job relatd instructions as requested, with reasonable accommodation

Customer Service Rep III (OH, Dayton)

Mon, 23 Jan 2012 00:00:00 GMT

Member Services Team Lead (OH, Dayton)

Mon, 23 Jan 2012 00:00:00 GMT

Job Summary: The Member Services Team Lead oversees day-to-day service center activities to assure service and performance objectives are achieved for the Medicaid, Medicare, and future lines of business. The Team Lead ensures all queues are appropriately staffed, and makes necessary adjustments to meet call volume demands. The Team Lead also oversees disciplinary action, PTO requests, schedule adherence, performance reporting of direct reports. Essential Functions: • Supervise staff for quality review, performance feedback, disciplinary issues and merit/bonus appraisal review. • Respond to incoming calls as needed to maintain service levels. • Provide correct and appropriate responses/information to service representatives, members and providers. • Facilitate timely resolution of member and provider issues. • Ensure that service representatives are available to respond to incoming calls in existing and future lines of business. • Coordinate incoming information and disseminate to staff to ensure accuracy of communication to internal and external customers. • Create, review, revise and enforce company and departmental policies and procedures. • Perform any other job related instructions as requested, with reasonable accommodation.

Manager Enterprise Project Office (OH, Dayton)

Fri, 20 Jan 2012 00:00:00 GMT

Job Summary: Responsible for directing Project Office team members and the various functions of the team. Collaborate with various business customers to establish, implement, develop, and control best practices for project management and requirements management throughout the organization. Use of SDLC and PMLC processes, tools and techniques. Use of industry best practices to further drive discipline and structure in the project management and requirements management functions.

Essential Functions:

· Responsible for ensuring project managers successfully deliver all projects contained in the project portfolio while meeting the strategic business requirements

· Drives the process of setting expectations with business owners.

· Responsible for working with multiple business owners to develop solution options to determine the feasibility of projects during the initiation phase

· Direct and coordinate activities of project personnel to ensure project progresses on schedule and within budget

· Review status reports prepared by project personnel, and modify schedules or plans as required

· Establish and maintain standards and procedures for project reporting and documentation

· Portfolios and contents are periodically reviewed and assessed for linkage, support and contribution to major goals and strategies.

· Information and reports are provided to governance committee on a scheduled basis about initiatives and portfolios; and questions, requests for information and discussions flow in both directions between the portfolio management function and the other governance entities

· Responsible for project management and requirements management metrics and tracking.

· Responsible for team development and growth.

CM Health Specialist - High Risk - Cleveland Area - North Region (OH, Cleveland)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: Responsible for working with RN and other members of the CareSource Care Coordination Centers’ Team* to collaboratively assist in the coordination of the care, services and health benefits for selected member populations. Encourage our members to seek the care and preventative services that they need to improve their overall health.

Essential Functions:

Coordination of Member Care:
1. Verify eligibility, previous enrollment history, demographics and current health status of each member
2. Contribute to assessments by gathering information from the member, family, provider and other stakeholders
3. Contribute to the development and implementation of care plan, defining specific issues, goals and interventions as agreed to by all parties
4. Assist with evaluation of care plan on an ongoing basis through member, family, provider and stakeholder contact
5. Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders
6. Contributes to team coordination and member outcomes
Documentation, Accreditation Requirements:
1. Maintain current and accurate documentation within the care management electronic record
2. Maintain appropriate documentation within protocols and guidelines of the Care Management program
Collaboration/Building Relationships:
1. Participate in meetings with providers to inform them of Care Management services and benefits available to members
Education/Training:
1. Assist in education of member/caregivers regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials
2. Precept and/ or mentor new staff
Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

Mobile Worker: Will work at different office locations established by CareSource and will typically work in established geographical area in the community; may require standing or sitting for long periods of time
Perform reasonable travel related duties including member home visits, provider visits, and community based visits as needed to ensure administration of the program
Required to use general office equipment, such as a telephone, photocopier, fax machine, and personal computer
Flexible hours, including possible evenings and/or weekends as needed to serve the needs of our members and may refer members to other CareSource resources

Director Health Services Clinical Operations (OH, Dayton)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: The Health Services Operations Director is accountable for collaborating with the Senior VP, Health Services to support the strategy and departmental projects as they relate to the Health Services areas, not limited to Care/Case and Disease Management, Care Management Support Services, Triage, Medical Management, Quality, HEDIS, Behavioral Health, Wellness, and Pharmacy operations. The individual will work closely with the department heads to ensure operational processes are properly developed and managed and the appropriate priority is assigned as they relate to the overall business plan. The individual will focus heavily on ensuring that regulatory and auditing requirements/ initiatives related to the Health Services area are in compliance.

Essential Functions:

Lead the development of processes to meet the business requirements of the Health Services Department
Actively work with Health Services Directors and Managers in the ongoing oversight of operational procedures as they relate to the Health Services Department
Responsible for development and maintenance of documentation related to workflow and process
Oversee and control process changes ensuring regulatory compliance and business goals are met
Direct and participate in the process of implementing new or revised processes and projects
Direct and participate in and drive the prioritization of Health Services projects
Direct and participate in the risk assessment associated with any changes in processes
Monitor and report on performance improvement via interacting with the various department heads
Ongoing collaboration with Health Services leadership to ensure that objectives are being defined and achieved
Provide assistance in the Health Services budgeting and financial forecasting/ analysis process
Work with the department heads to create comprehensive reports, and monitor on a weekly, monthly and/or annual basis
Participate in Health Services committee meetings
Develop and maintain an in-depth knowledge of the company’s business and regulatory environments
Assist in strategic and business planning
Direct, manage and oversee the work of the Health Service Business Analysts
Perform any other job related instructions as requested, with reasonable accommodation

LPN Care Manager - High Risk - Cleveland Area - North Region (OH, Cleveland)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: Responsible for working with RN and other members of the care team to collaboratively assist in the coordination of the care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources within the scope of the LPN licensure.

Essential Functions:

Coordination of Member Care
1. Verify eligibility, previous enrollment history, demographics and current health status of each member
2. Contribute to assessments by gathering information from the member, family, provider and other stakeholders
3. Contribute to the development and implementation of care plan, defining specific issues, goals and interventions as agreed to by all parties
4. Assist with evaluation of care plan on an ongoing basis through member, family, provider and stakeholder contact
5. Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders
6. Contributes to team coordination and member outcomes.
Documentation, Accreditation Requirements:
1. Maintain current and accurate documentation within the care management electronic record
2. Maintain appropriate documentation within protocols and guidelines of the Care Management program
Collaboration/Building Relationships
1. Participate in meetings with providers to inform them of Care Management services and benefits available to members
Education/Training:
1. Assist in education of member/caregivers regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials
2. Precept and/ or mentor new staff
Perform any other job related instructions as requested, with or without reasonable accommodation

Work Environment/Physical Requirements:

General office setting: May require standing and/or sitting for long periods of time; noise level is generally moderate to quiet
Required to use general office equipment, such as a telephone, photocopier, fax machine, and personal computer
Perform reasonable travel related duties including, member home visits, provider visits, and community based visits as needed to ensure administration of the program
Flexible hours, including possible evenings, weekends and/or on-call as needed

LPN Care Manager - High Risk - Columbus Area - Central Region (OH, Columbus)

Mon, 16 Jan 2012 00:00:00 GMT

Essential Functions:

Coordination of Member Care
1. Verify eligibility, previous enrollment history, demographics and current health status of each member
2. Contribute to assessments by gathering information from the member, family, provider and other stakeholders
3. Contribute to the development and implementation of care plan, defining specific issues, goals and interventions as agreed to by all parties
4. Assist with evaluation of care plan on an ongoing basis through member, family, provider and stakeholder contact
5. Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders
6. Contributes to team coordination and member outcomes.
Documentation, Accreditation Requirements:
1. Maintain current and accurate documentation within the care management electronic record
2. Maintain appropriate documentation within protocols and guidelines of the Care Management program
Collaboration/Building Relationships
1. Participate in meetings with providers to inform them of Care Management services and benefits available to members
Education/Training:
1. Assist in education of member/caregivers regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials
2. Precept and/ or mentor new staff
Perform any other job related instructions as requested, with or without reasonable accommodation

Work Environment/Physical Requirements:

General office setting: May require standing and/or sitting for long periods of time; noise level is generally moderate to quiet
Required to use general office equipment, such as a telephone, photocopier, fax machine, and personal computer
Perform reasonable travel related duties including, member home visits, provider visits, and community based visits as needed to ensure administration of the program
Flexible hours, including possible evenings, weekends and/or on-call as needed

LPN Care Manager - High Risk - West Region - Toledo Area (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

Essential Functions:

Coordination of Member Care
1. Verify eligibility, previous enrollment history, demographics and current health status of each member
2. Contribute to assessments by gathering information from the member, family, provider and other stakeholders
3. Contribute to the development and implementation of care plan, defining specific issues, goals and interventions as agreed to by all parties
4. Assist with evaluation of care plan on an ongoing basis through member, family, provider and stakeholder contact
5. Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders
6. Contributes to team coordination and member outcomes.
Documentation, Accreditation Requirements:
1. Maintain current and accurate documentation within the care management electronic record
2. Maintain appropriate documentation within protocols and guidelines of the Care Management program
Collaboration/Building Relationships
1. Participate in meetings with providers to inform them of Care Management services and benefits available to members
Education/Training:
1. Assist in education of member/caregivers regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials
2. Precept and/ or mentor new staff
Perform any other job related instructions as requested, with or without reasonable accommodation

Work Environment/Physical Requirements:

General office setting: May require standing and/or sitting for long periods of time; noise level is generally moderate to quiet
Required to use general office equipment, such as a telephone, photocopier, fax machine, and personal computer
Perform reasonable travel related duties including, member home visits, provider visits, and community based visits as needed to ensure administration of the program
Flexible hours, including possible evenings, weekends and/or on-call as needed

Patient Navigator - Cleveland Area - Medina, Portage, Trumbull, Ottawa, Erie - North Region (OH, Cleveland)

Mon, 16 Jan 2012 00:00:00 GMT

Essential Functions:

1. Guide patients through the healthcare system by assisting with access to healthcare as directed by the CareSource RN Case Manager:

1. Accompanying patients to appointments and other social service encounters when necessary
2. Coordinating logistics for plan adherence – reminders, transportation, and childcare arrangements
3. Ensuring that medication adherence issues are addressed by ongoing reporting of issues to the CareSource RN Case Manager
4. Supporting patient family members

2. Participate in the implementation of comprehensive care plans:

1. Working with CareSource members in various community, care delivery and administrative settings
2. Developing relationships with community providers and resources
3. Managing resources through interdisciplinary collaboration to achieve optimal patient outcomes
4. Demonstrating effective communication skills with all stakeholders (e.g., members, team members, community providers and resources)
Maintain knowledge and understanding of business:
1. Providing timely and accurate documentation
2. Actively participating in team meetings
3. Developing and maintaining knowledge of the company’s business and regulatory environments
Travel:

1. Travel within the community and conduct face-to-face meetings with high-risk members, treatment plan personnel, providers and community leaders
2. Abide by the CareSource’s travel policy

Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

Mobile Worker: Will work at different office locations established by CareSource and will typically work in established geographical area in the community; may

Patient Navigator - Columbus Area - Morrow, Holmes, Athens, Noble, Logan - Central Region (OH, Columbus)

Mon, 16 Jan 2012 00:00:00 GMT

Essential Functions:

1. Guide patients through the healthcare system by assisting with access to healthcare as directed by the CareSource RN Case Manager:

1. Accompanying patients to appointments and other social service encounters when necessary
2. Coordinating logistics for plan adherence – reminders, transportation, and childcare arrangements
3. Ensuring that medication adherence issues are addressed by ongoing reporting of issues to the CareSource RN Case Manager
4. Supporting patient family members

2. Participate in the implementation of comprehensive care plans:

1. Working with CareSource members in various community, care delivery and administrative settings
2. Developing relationships with community providers and resources
3. Managing resources through interdisciplinary collaboration to achieve optimal patient outcomes
4. Demonstrating effective communication skills with all stakeholders (e.g., members, team members, community providers and resources)
Maintain knowledge and understanding of business:
1. Providing timely and accurate documentation
2. Actively participating in team meetings
3. Developing and maintaining knowledge of the company’s business and regulatory environments
Travel:

1. Travel within the community and conduct face-to-face meetings with high-risk members, treatment plan personnel, providers and community leaders
2. Abide by the CareSource’s travel policy

Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

Mobile Worker: Will work at different office locations established by CareSource and will typically work in established geographical area in the community; may

Patient Navigator - South Region - Hamilton County (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

Essential Functions:

1. Guide patients through the healthcare system by assisting with access to healthcare as directed by the CareSource RN Case Manager:

1. Accompanying patients to appointments and other social service encounters when necessary
2. Coordinating logistics for plan adherence – reminders, transportation, and childcare arrangements
3. Ensuring that medication adherence issues are addressed by ongoing reporting of issues to the CareSource RN Case Manager
4. Supporting patient family members

2. Participate in the implementation of comprehensive care plans:

1. Working with CareSource members in various community, care delivery and administrative settings
2. Developing relationships with community providers and resources
3. Managing resources through interdisciplinary collaboration to achieve optimal patient outcomes
4. Demonstrating effective communication skills with all stakeholders (e.g., members, team members, community providers and resources)
Maintain knowledge and understanding of business:
1. Providing timely and accurate documentation
2. Actively participating in team meetings
3. Developing and maintaining knowledge of the company’s business and regulatory environments
Travel:

1. Travel within the community and conduct face-to-face meetings with high-risk members, treatment plan personnel, providers and community leaders
2. Abide by the CareSource’s travel policy

Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

Mobile Worker: Will work at different office locations established by CareSource and will typically work in established geographical area in the community; may

Patient Navigator - South Region - Scioto, Gallia, Lawrence County (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

Essential Functions:

1. Guide patients through the healthcare system by assisting with access to healthcare as directed by the CareSource RN Case Manager:

1. Accompanying patients to appointments and other social service encounters when necessary
2. Coordinating logistics for plan adherence – reminders, transportation, and childcare arrangements
3. Ensuring that medication adherence issues are addressed by ongoing reporting of issues to the CareSource RN Case Manager
4. Supporting patient family members

2. Participate in the implementation of comprehensive care plans:

1. Working with CareSource members in various community, care delivery and administrative settings
2. Developing relationships with community providers and resources
3. Managing resources through interdisciplinary collaboration to achieve optimal patient outcomes
4. Demonstrating effective communication skills with all stakeholders (e.g., members, team members, community providers and resources)
Maintain knowledge and understanding of business:
1. Providing timely and accurate documentation
2. Actively participating in team meetings
3. Developing and maintaining knowledge of the company’s business and regulatory environments
Travel:

1. Travel within the community and conduct face-to-face meetings with high-risk members, treatment plan personnel, providers and community leaders
2. Abide by the CareSource’s travel policy

Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

Mobile Worker: Will work at different office locations established by CareSource and will typically work in established geographical area in the community; may

Patient Navigator- Lima Area - West Region (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

Essential Functions:

1. Guide patients through the healthcare system by assisting with access to healthcare as directed by the CareSource RN Case Manager:

1. Accompanying patients to appointments and other social service encounters when necessary
2. Coordinating logistics for plan adherence – reminders, transportation, and childcare arrangements
3. Ensuring that medication adherence issues are addressed by ongoing reporting of issues to the CareSource RN Case Manager
4. Supporting patient family members

2. Participate in the implementation of comprehensive care plans:

1. Working with CareSource members in various community, care delivery and administrative settings
2. Developing relationships with community providers and resources
3. Managing resources through interdisciplinary collaboration to achieve optimal patient outcomes
4. Demonstrating effective communication skills with all stakeholders (e.g., members, team members, community providers and resources)
Maintain knowledge and understanding of business:
1. Providing timely and accurate documentation
2. Actively participating in team meetings
3. Developing and maintaining knowledge of the company’s business and regulatory environments
Travel:

1. Travel within the community and conduct face-to-face meetings with high-risk members, treatment plan personnel, providers and community leaders
2. Abide by the CareSource’s travel policy

Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

Mobile Worker: Will work at different office locations established by CareSource and will typically work in established geographical area in the community; may

Patient Navigator- Toledo Area - West Region (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

Essential Functions:

1. Guide patients through the healthcare system by assisting with access to healthcare as directed by the CareSource RN Case Manager:

1. Accompanying patients to appointments and other social service encounters when necessary
2. Coordinating logistics for plan adherence – reminders, transportation, and childcare arrangements
3. Ensuring that medication adherence issues are addressed by ongoing reporting of issues to the CareSource RN Case Manager
4. Supporting patient family members

2. Participate in the implementation of comprehensive care plans:

1. Working with CareSource members in various community, care delivery and administrative settings
2. Developing relationships with community providers and resources
3. Managing resources through interdisciplinary collaboration to achieve optimal patient outcomes
4. Demonstrating effective communication skills with all stakeholders (e.g., members, team members, community providers and resources)
Maintain knowledge and understanding of business:
1. Providing timely and accurate documentation
2. Actively participating in team meetings
3. Developing and maintaining knowledge of the company’s business and regulatory environments
Travel:

1. Travel within the community and conduct face-to-face meetings with high-risk members, treatment plan personnel, providers and community leaders
2. Abide by the CareSource’s travel policy

Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

Mobile Worker: Will work at different office locations established by CareSource and will typically work in established geographical area in the community; may

Social Worker - High Risk - Cleveland Area - North Region (OH, Cleveland)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: Responsible for working with RN and other members of the care team to collaboratively assist in the coordination of the care, services and health benefits for selected member populations. Identify available resources to meet the social needs that affect a member’s medical condition, treatment and recovery. Assure that members and families are knowledgeable of available community resources and how to access them.

Essential Functions:

Coordination of Member Care:
1. Verify eligibility, previous enrollment history, demographics and current health status of each member
2. Contribute to assessments by gathering information from the member, family, provider and other stakeholders
3. Contribute to the development and implementation of care plan, defining specific issues, goals and interventions as agreed to by all parties
4. Assist with evaluation of the care plan on an ongoing basis through member, family, provider and stakeholder contact.
5. Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders
6. Identify appropriate resources to address member’s psychosocial, financial and other needs related to healthcare.
7. Contributes to team coordination and member outcomes

2. Documentation, Accreditation Requirements:

1. Maintain current and accurate documentation within the Care Management electronic record
2. Maintain appropriate documentation within protocols and guidelines of the Care Management program

3. Collaboration / Building Relationships:

a. Act as a liaison to social services/community resources and government agencies

b. Participate in meetings with providers to inform them of Care Management services and benefits available to members

4. Education / Training:

a. Knowledgeable of local, state and federal resources

b. Assist in education of member/caregiver regarding how to access available community resources

c. Serve as resource and provide updates on social services for care management team

d. Precept and/or mentor new staff

5. Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

1. Mobile Worker: Will work at different office locations established by CareSource and will typically work in established geographical area in the community; may be required to stand and/or sit for long periods of time

2. Perform reasonable travel related duties includin

Social Worker - High Risk - Columbus Area - Central Region (OH, Columbus)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: Responsible for working with RN and other members of the care team to collaboratively assist in the coordination of the care, services and health benefits for selected member populations. Identify available resources to meet the social needs that affect a member’s medical condition, treatment and recovery. Assure that members and families are knowledgeable of available community resources and how to access them.

Essential Functions:

Coordination of Member Care:
1. Verify eligibility, previous enrollment history, demographics and current health status of each member
2. Contribute to assessments by gathering information from the member, family, provider and other stakeholders
3. Contribute to the development and implementation of care plan, defining specific issues, goals and interventions as agreed to by all parties
4. Assist with evaluation of the care plan on an ongoing basis through member, family, provider and stakeholder contact.
5. Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders
6. Identify appropriate resources to address member’s psychosocial, financial and other needs related to healthcare.
7. Contributes to team coordination and member outcomes

2. Documentation, Accreditation Requirements:

1. Maintain current and accurate documentation within the Care Management electronic record
2. Maintain appropriate documentation within protocols and guidelines of the Care Management program

3. Collaboration / Building Relationships:

a. Act as a liaison to social services/community resources and government agencies

b. Participate in meetings with providers to inform them of Care Management services and benefits available to members

4. Education / Training:

a. Knowledgeable of local, state and federal resources

b. Assist in education of member/caregiver regarding how to access available community resources

c. Serve as resource and provide updates on social services for care management team

d. Precept and/or mentor new staff

5. Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

2. Perform reasonable travel related duties includin

Social Worker - High Risk - South Region - Clermont, Adams, Brown, Pike, Jackson (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: Responsible for working with RN and other members of the care team to collaboratively assist in the coordination of the care, services and health benefits for selected member populations. Identify available resources to meet the social needs that affect a member’s medical condition, treatment and recovery. Assure that members and families are knowledgeable of available community resources and how to access them.

Essential Functions:

Coordination of Member Care:
1. Verify eligibility, previous enrollment history, demographics and current health status of each member
2. Contribute to assessments by gathering information from the member, family, provider and other stakeholders
3. Contribute to the development and implementation of care plan, defining specific issues, goals and interventions as agreed to by all parties
4. Assist with evaluation of the care plan on an ongoing basis through member, family, provider and stakeholder contact.
5. Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders
6. Identify appropriate resources to address member’s psychosocial, financial and other needs related to healthcare.
7. Contributes to team coordination and member outcomes

2. Documentation, Accreditation Requirements:

1. Maintain current and accurate documentation within the Care Management electronic record
2. Maintain appropriate documentation within protocols and guidelines of the Care Management program

3. Collaboration / Building Relationships:

a. Act as a liaison to social services/community resources and government agencies

b. Participate in meetings with providers to inform them of Care Management services and benefits available to members

4. Education / Training:

a. Knowledgeable of local, state and federal resources

b. Assist in education of member/caregiver regarding how to access available community resources

c. Serve as resource and provide updates on social services for care management team

d. Precept and/or mentor new staff

5. Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

2. Perform reasonable travel related duties includin

RN Case Manager - High Risk - Scioto, Gallia, Lawrence - South Region (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

***Scioto, Gallia, Lawrence County***

Essential Functions:

1. Coordination of Member Care:

a. Serves as member’s accountable point of contact

b. Verify eligibility, previous enrollment history, demographics and current health status of each member

c. Complete assessments by gathering information from the member, family, provider and other stakeholders

d. Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties

f. Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders

g. Responsible for team coordination and member outcomes

2. Oversight:

a. Oversee (point of contact) the care planning and execution of meeting member needs

b. Arrange and coordinate services with community partners to maximize utilization of appropriate community resources and support groups

3. Documentation, Accreditation Requirements:

a. Maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b. Maintain appropriate documentation within protocols and guidelines of the Care Management program

4. Collaboration/Building Relationships:

a. Participate in meetings with providers to inform them of Care Management services and benefits available to members

5. Education/Training:

a. Assist in education of member/caregiver regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials

b. Precept and/or mentor new staff

6. Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

RN Case Manager - High Risk - Southern Cleveland Area (OH, Cleveland)

Mon, 16 Jan 2012 00:00:00 GMT

Looking for RN's located in the following counties***Erie, Huron, Lorain, Medina, Ashland, Wayne, Stark ***

Job Summary: Coordinate the care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. Coordinate quarterly face-to-face interviews with each high-risk member. This position is a collaborative team role and will be responsible for conducting assessments, treatment plans and evaluation of high-risk members.

Essential Functions:

1.    Coordination of Member Care:

a.    Serves as member’s accountable point of contact

b.    Verify eligibility, previous enrollment history, demographics and current health status of each member

c.    Complete assessments by gathering information from the member, family, provider and other stakeholders

d.    Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties

e.    Monitor and evaluate care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

f.     Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders

g.    Responsible for team coordination and member outcomes

2.    Oversight:

a.    Oversee (point of contact) the care planning and execution of meeting member needs

b.    Arrange and coordinate services with community partners to maximize utilization of appropriate community resources and support groups

3.    Documentation, Accreditation Requirements:

a.    Maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b.    Maintain appropriate documentation within protocols and guidelines of the Care Management program

4.    Collaboration/Building Relationships:

a.    Participate in meetings with providers to inform them of Care Management services and benefits available to members

5.    Education/Training:

a.    Assist in education of member/caregiver regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials

b.    Precept and/or mentor new staff

6.    Perform any other job related instructions as requested, with reasonable acco

RN Case Manager - High Risk - West Region - Toledo Area (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: Coordinate the care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. Coordinate quarterly face-to-face interviews with each high-risk member. This position is a collaborative team role and will be responsible for conducting assessments, treatment plans and evaluation of high-risk members.

Essential Functions:

1.    Coordination of Member Care:

a.    Serves as member’s accountable point of contact

b.    Verify eligibility, previous enrollment history, demographics and current health status of each member

c.    Complete assessments by gathering information from the member, family, provider and other stakeholders

d.    Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties

e.    Monitor and evaluate care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

f.     Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders

g.    Responsible for team coordination and member outcomes

2.    Oversight:

a.    Oversee (point of contact) the care planning and execution of meeting member needs

b.    Arrange and coordinate services with community partners to maximize utilization of appropriate community resources and support groups

3.    Documentation, Accreditation Requirements:

a.    Maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b.    Maintain appropriate documentation within protocols and guidelines of the Care Management program

4.    Collaboration/Building Relationships:

a.    Participate in meetings with providers to inform them of Care Management services and benefits available to members

5.    Education/Training:

a.    Assist in education of member/caregiver regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials

b.    Precept and/or mentor new staff

6.    Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

1.    Mob

RN Case Manager - High Risk - Clermont, Adams, Fayette, Jackson - South Region (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

***Clermont, Adams, Highland, Brown, Pike, Fayette, Jackson County***

Job Summary: Coordinate the care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. Coordinate quarterly face-to-face interviews with each high-risk member. This position is a collaborative team role and will be responsible for conducting assessments, treatment plans and evaluation of high-risk members.

Essential Functions:

1.    Coordination of Member Care:

a.    Serves as member’s accountable point of contact

b.    Verify eligibility, previous enrollment history, demographics and current health status of each member

c.    Complete assessments by gathering information from the member, family, provider and other stakeholders

d.    Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties

e.    Monitor and evaluate care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

f.     Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders

g.    Responsible for team coordination and member outcomes

2.    Oversight:

a.    Oversee (point of contact) the care planning and execution of meeting member needs

b.    Arrange and coordinate services with community partners to maximize utilization of appropriate community resources and support groups

3.    Documentation, Accreditation Requirements:

a.    Maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b.    Maintain appropriate documentation within protocols and guidelines of the Care Management program

4.    Collaboration/Building Relationships:

a.    Participate in meetings with providers to inform them of Care Management services and benefits available to members

5.    Education/Training:

a.    Assist in education of member/caregiver regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials

b.    Precept and/or mentor new staff

6.    Perform any other job related instructions as requested, with reasonable accommodation

Work Environ

RN Case Manager - High Risk - Columbus Area - Central Region (OH, Columbus)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: Coordinate the care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. Coordinate quarterly face-to-face interviews with each high-risk member. This position is a collaborative team role and will be responsible for conducting assessments, treatment plans and evaluation of high-risk members.

Essential Functions:

1.    Coordination of Member Care:

a.    Serves as member’s accountable point of contact

b.    Verify eligibility, previous enrollment history, demographics and current health status of each member

c.    Complete assessments by gathering information from the member, family, provider and other stakeholders

d.    Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties

e.    Monitor and evaluate care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

f.     Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders

g.    Responsible for team coordination and member outcomes

2.    Oversight:

a.    Oversee (point of contact) the care planning and execution of meeting member needs

b.    Arrange and coordinate services with community partners to maximize utilization of appropriate community resources and support groups

3.    Documentation, Accreditation Requirements:

a.    Maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b.    Maintain appropriate documentation within protocols and guidelines of the Care Management program

4.    Collaboration/Building Relationships:

a.    Participate in meetings with providers to inform them of Care Management services and benefits available to members

5.    Education/Training:

a.    Assist in education of member/caregiver regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials

b.    Precept and/or mentor new staff

6.    Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

1.    Mob

RN Case Manager - High Risk - Hamilton County - South Region (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

***Hamilton County, Ohio***

Job Summary: Coordinate the care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. Coordinate quarterly face-to-face interviews with each high-risk member. This position is a collaborative team role and will be responsible for conducting assessments, treatment plans and evaluation of high-risk members.

Essential Functions:

1.    Coordination of Member Care:

a.    Serves as member’s accountable point of contact

b.    Verify eligibility, previous enrollment history, demographics and current health status of each member

c.    Complete assessments by gathering information from the member, family, provider and other stakeholders

d.    Develop and implement care plan, defining specific issues, goals and interventions as agreed to by all parties

e.    Monitor and evaluate care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

f.     Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders

g.    Responsible for team coordination and member outcomes

2.    Oversight:

a.    Oversee (point of contact) the care planning and execution of meeting member needs

b.    Arrange and coordinate services with community partners to maximize utilization of appropriate community resources and support groups

3.    Documentation, Accreditation Requirements:

a.    Maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b.    Maintain appropriate documentation within protocols and guidelines of the Care Management program

4.    Collaboration/Building Relationships:

a.    Participate in meetings with providers to inform them of Care Management services and benefits available to members

5.    Education/Training:

a.    Assist in education of member/caregiver regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials

b.    Precept and/or mentor new staff

6.    Perform any other job related instructions as requested, with reasonable accommodation

Work Environment/Physical Requirements:

RN Team Lead II CM - High Risk - West Region - Toledo Area (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: Under the direction of the manager, provide day-to-day direction and supervision of staff assigned to the High Risk Care Management program. Provide support, direction and assistance to CM staff. Give effective and timely feedback to staff in regards to performance outcomes and progress toward goals. Assist the High Risk Care Management Team in coordinating care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. May conduct and/or participate in the quarterly face-to-face interviews with each high-risk member. Member of the collaborative team and may provide input to the assessments, treatment plans and evaluation of high-risk members. Complete all responsibilities ensuring compliance with all Federal, State, and Accreditation requirements.

Essential Functions:

1.    Coordination of Member Care:

a.    Verify eligibility, previous enrollment history, demographics and current health status of each member as appropriate.

b.    May complete or contribute to assessments by gathering information from the member, family, provider and other stakeholders

c.    May contribute to the development and implementation of the care plan, defining specific issues, goals and interventions as agreed to by all parties

d.    May assist in monitoring and evaluation of care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

e.    May assist in the facilitation and coordination of services based upon the care treatment plan developed in collaboration with all stakeholders

f.     Responsible for overall team coordination and member outcomes.

2.    Oversight:

a.    Oversee the care planning and execution of meeting member needs

b.    May assist in arranging and coordinating services with community partners to maximize utilization of appropriate community resources and support groups

c.    Monitoring of scheduling/work allocation

d.    Provides quality monitoring and conducts regularly scheduled one-on-one meetings with all team members

3.    Documentation, Accreditation Requirements:

a.    Oversee and/or maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b.    Oversee and/or maintain appropriate documentation within protocols and guidelines of the Care Man

RN Triage Nurse (OH, Dayton)

Mon, 16 Jan 2012 00:00:00 GMT

Use decision support software in order to perform telephonic clinical triage and health information services for CSMG managed health plans and external clients. Function as a patient advocate by facilitating accessibility to healthcare and provide collaborative services for other CSMG departments.

Manager Care Management- High Risk - Cincinnati Area - South Region (OH, Various)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: Assist the High Risk Care Management Team in coordinating care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. May conduct and/or participate in the quarterly face-to-face interviews with each high-risk member. Member of the collaborative team and may provide input to the assessments, treatment plans and evaluation of high-risk members. Actively oversee the performance of the High Risk Care Management teams to ensure all state and accreditation requirements are achieved. Constantly monitor staff performance for quality measures, workloads and productivity outcomes.

Essential Functions:

1.    Coordination of Member Care:

a.    Verify eligibility, previous enrollment history, demographics and current health status of each member as appropriate

b.    May complete or contribute to assessments by gathering information from the member, family, provider and other stakeholders

c.    May contribute to the development and implementation of the care plan, defining specific issues, goals and interventions as agreed to by all parties

d.    May assist in monitoring and evaluation of care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

e.    May assist in the facilitation and coordination of services based upon the care treatment plan developed in collaboration with all stakeholders

f.     Responsible for overall team coordination and member outcomes.

2.    Oversight:

a.    Oversee the care planning and execution of meeting member needs

b.    May assist in arranging and coordinating services with community partners to maximize utilization of appropriate community resources and support groups

c.    Monitoring of scheduling/work allocation

d.    Provides quality monitoring and conducts regularly scheduled one-on-one meetings with all team members

e.    Monitor and analyze High Risk Care Management data and reporting

3.    Documentation, Accreditation Requirements:

a.    Oversee and/or maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b.    Oversee and/or maintain appropriate documentation within protocols and guidelines of the Care Management program

c.    Actively oversee the performance of the High Risk

RN Team Lead II CM - High Risk - Cleveland Area - North Region (OH, Cleveland)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: Under the direction of the manager, provide day-to-day direction and supervision of staff assigned to the High Risk Care Management program. Provide support, direction and assistance to CM staff. Give effective and timely feedback to staff in regards to performance outcomes and progress toward goals. Assist the High Risk Care Management Team in coordinating care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. May conduct and/or participate in the quarterly face-to-face interviews with each high-risk member. Member of the collaborative team and may provide input to the assessments, treatment plans and evaluation of high-risk members. Complete all responsibilities ensuring compliance with all Federal, State, and Accreditation requirements.

Essential Functions:

1.    Coordination of Member Care:

a.    Verify eligibility, previous enrollment history, demographics and current health status of each member as appropriate.

b.    May complete or contribute to assessments by gathering information from the member, family, provider and other stakeholders

c.    May contribute to the development and implementation of the care plan, defining specific issues, goals and interventions as agreed to by all parties

d.    May assist in monitoring and evaluation of care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

e.    May assist in the facilitation and coordination of services based upon the care treatment plan developed in collaboration with all stakeholders

f.     Responsible for overall team coordination and member outcomes.

2.    Oversight:

a.    Oversee the care planning and execution of meeting member needs

b.    May assist in arranging and coordinating services with community partners to maximize utilization of appropriate community resources and support groups

c.    Monitoring of scheduling/work allocation

d.    Provides quality monitoring and conducts regularly scheduled one-on-one meetings with all team members

3.    Documentation, Accreditation Requirements:

a.    Oversee and/or maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b.    Oversee and/or maintain appropriate documentation within protocols and guidelines of the Care Man

RN Team Lead II CM - High Risk - Columbus Area - Central Region (OH, Columbus)

Mon, 16 Jan 2012 00:00:00 GMT

Job Summary: Under the direction of the manager, provide day-to-day direction and supervision of staff assigned to the High Risk Care Management program. Provide support, direction and assistance to CM staff. Give effective and timely feedback to staff in regards to performance outcomes and progress toward goals. Assist the High Risk Care Management Team in coordinating care, services and health benefits for selected member populations. Monitor and promote effective utilization of healthcare resources through clinical variance and benefits management. May conduct and/or participate in the quarterly face-to-face interviews with each high-risk member. Member of the collaborative team and may provide input to the assessments, treatment plans and evaluation of high-risk members. Complete all responsibilities ensuring compliance with all Federal, State, and Accreditation requirements.

Essential Functions:

1.    Coordination of Member Care:

a.    Verify eligibility, previous enrollment history, demographics and current health status of each member as appropriate.

b.    May complete or contribute to assessments by gathering information from the member, family, provider and other stakeholders

c.    May contribute to the development and implementation of the care plan, defining specific issues, goals and interventions as agreed to by all parties

d.    May assist in monitoring and evaluation of care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

e.    May assist in the facilitation and coordination of services based upon the care treatment plan developed in collaboration with all stakeholders

f.     Responsible for overall team coordination and member outcomes.

2.    Oversight:

a.    Oversee the care planning and execution of meeting member needs

b.    May assist in arranging and coordinating services with community partners to maximize utilization of appropriate community resources and support groups

c.    Monitoring of scheduling/work allocation

d.    Provides quality monitoring and conducts regularly scheduled one-on-one meetings with all team members

3.    Documentation, Accreditation Requirements:

a.    Oversee and/or maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record

b.    Oversee and/or maintain appropriate documentation within protocols and guidelines of the Care Man

Recruiter - Temporary Assignment - Travel Required (OH, Dayton)

Thu, 12 Jan 2012 00:00:00 GMT

***This is a temporary assignment lasting 4-6 months***

Position is Dayton, Ohio based with travel to Cleveland, Columbus, & Cincinnati.

Job Summary: The Temporary Recruiter is responsible for delivering recruiting support throughout the organization. This will be achieved through the development of recruiting plans, employing traditional sourcing strategies and resources as well as developing new, creative recruiting ideas. The Temporar Recruiter, in conjunction with the Human Resources Consultant, will play a critical role in ensuring we are hiring the best possible talent. Essential Functions: • Complete facets of recruiting cycle to assist HR Consultants. Responsibilities include posting positions (internally and externally), screening and reference checking. • Develop a pool of qualified candidates in advance of need. • Research and recommend new sources for active and passive candidate recruiting. • Post openings in newspaper advertisements, with professional organizations, and in other position appropriate venues. • Utilize the Internet for recruitment. --Post positions to appropriate Internet sources. --Research new ways of using the Internet for recruitment. --Use social and professional networking sites to identify and source candidates. • Attend career fairs for recruiting and company recognition. • Review applicants to evaluate if they meet the position requirements. • Conduct prescreening interviews. • Assist in performing reference and background checks for potential employees. • Perform any other job related instructions as requested, with reasonable accommodation.

Application Developer � Applications (OH, Dayton)

Tue, 03 Jan 2012 00:00:00 GMT

Job Summary:        The application developer’s role is to design, code, test, and analyze software programs and applications. This includes researching, designing, documenting, and modifying software specifications throughout the production lifecycle. The software developer will also analyze and amend software errors in a timely and accurate fashion and provide status reports where required. This role will work closely with SAQ and team members to understand business and functional requirements that drive technical design and quality solutions. Responsibilities may also include mentoring Jr. Developers as needed and working with Sr. developers on component and architecture design. Must have experience in systems analysis, design and a solid understanding of development, quality assurance and integration methodologies.

Essential Functions:

Strategy & Planning

·         Assist other developers, analysts, and designers in conceptualizing and developing new software programs and applications.

·         Plan phases of the software development life cycle (SDLC) for a variety of projects.

·         Assist in the preparation and documentation of software requirements and specifications.

·         Research and document requirements of software users.

Acquisition & Deployment

·         Conduct research on emerging application development software products, languages, and standards in support of procurement and development efforts.

·         Recommend, schedule, and perform software improvements and upgrades.

Operational Management

·         Consistently write, translate, and code software programs and applications according to functional/technical specifications that meet business requirements.

·         Run and monitor software performance tests on new and existing programs for the purposes of correcting errors, isolating areas for improvement, and general debugging.

·         Administer critical analysis of test results and deliver solutions to problem areas.

·         Generate statistics and prepare and write reports for management and/or team members on the status of the programming process.

·         Assist in the development and maintenance of user manuals and guidelines.

·     &

Software Quality Analyst (OH, Dayton)

Tue, 03 Jan 2012 00:00:00 GMT
Job Summary: This position will work with team members, developers and department managers to develop, maintain, implement and execute a quality assurance process. The role is responsible to develop routine tests, and coordinate the testing efforts for all assigned applications and code base. Essential Functions: � Complete business analysis � Manage the requirements gathering process � Obtain and document business and system requirements � Document workflows � Provide requirements to development teams and participate in collaborative design sessions � Create and document test cases for all documented requirements � Manage and execute testing for all test cases: types include integration, certification, user acceptance, system, regression, and load tests. � Monitor, measure, and report metrics based on the results of all tests � Measure, Evaluate and test new or modified software programs and software development procedures used to verify that programs function according to user requirements and conform to established guidelines � Write, revise, and verify quality standards and test procedures for program design and product evaluation in order to economically and efficiently attain a high quality of software � Follow established quality assurance practices � Follow defined quality methods � Abide by quality controls and documentation procedures � Develop and maintain test plans, manual and automated test scripts for user interface, functionality, system and "ad-hoc testing" � Execute regression tests, functional tests and data tests � Report, track and determine priority of reported bugs promoting quality achievement and performance improvement � Maintain awareness of the business context of software � Ensure compliance with local, state, national and international standards and legislation � Define quality procedures in conjunction with operating staff � Collate and analyze performance data and charts against defined parameters � Ensure tests and procedures are properly understood, carried out and evaluated and that product modifications are investigated if necessary � Write technical and management systems reports � Monitor performance by gathering relevant data and producing statistical reports � Conduct tests on computer software programs to make sure the programs perform properly and are easy to use � Complete tests to determine weaknesses in software code � Review new or modified software, including documentation, diagram, and flow chart, to determine if a program will perform according to user requests and standards and conform to guidelines � Recommend program improvements or corrections to programmers � Identify program processing errors � Implement automated test programs to ascertain the validity of results, accuracy, reliability, and conformance to established standards � Identify differences between established standards and user applications and suggest modifications to conform to standards

Senior Systems Engineer (OH, Dayton)

Tue, 03 Jan 2012 00:00:00 GMT

Job Summary: Provide technical guidance, training, and work direction to less experienced system engineers. Develop new programs, systems and/or computing infrastructure. Identify and document business requirements for new development projects and prepare detailed technical specifications from which programs or infrastructure can be built. Lead service support activities and initiatives.

Essential Functions:

·         Coordinate vendor relationships and commitments on project involvement/deliverables.

·         Design and implement systematic approaches and alternatives

·         Conduct preliminary studies to define needs and determine feasibility.

·         Confer with clients and analyze business/functional requirements.

·         Develop procedures for moving program changes, enhancements, etc. into IT production processing.

·         Understand and relate business/functional requirements to application/infrastructure requirements.

·         Initiate and lead support activities including problem analysis, technical evaluation, work estimates and implementation services.

·         Coordinate support or project activities with all applicable constituents including customers using the systems, IT staff supporting the systems, vendors/third parties, and/or business managers.

·         Identify and lead, as assigned, resources and communications to facilitate work completion.

·         Train and provide guidance to new IT team members to assist them in orientation to policies, procedures and responsibilities.

·         Serve as an escalation point for system engineers to escalate problems and inquiries requiring further evaluation beyond the associated skill level.

·         Represent IT in project and/or business meeting and engagements.

·         Lead conference calls or visits with vendors/third parties.

·         Introduce new customers to IT services to assist in familiarizing them with appropriate systems, services, policies and procedures.

Perform any other job related instructions as requested, with reasonable accommodation.

Systems Engineer (OH, Dayton)

Tue, 03 Jan 2012 00:00:00 GMT
Essential Functions: 1. Responsible for application development & integration supporting business objectives while providing expertise in software development lifecycle phases from concept and design to testing. � Analyzes, designs and builds component-based applications � Support systematic approaches to application integration. � Works on new and existing applications along with enhancements. � Performs hands-on coding, mentors junior developers and assists in architecting web content solutions. � Serves as liaison to internal customers, research groups and various business support areas. 2. Identify and document business requirements for new development projects and prepare detailed technical specifications from which programs or infrastructure can be built. � Conduct preliminary studies to define needs and determine feasibility � Confer with clients and analyze business/functional requirements � Develop procedures for moving program changes, enhancements, etc. into IT production processing. � Understand and relate business/functional requirements to application & infrastructure requirements. 3. Lead service support activities and initiatives � Initiate and lead support activities including problem analysis, technical evaluation, work estimates, and implementation services. � Coordinate support or project activities with all applicable constituents including customers using the systems, IT staff supporting the systems, vendors/third parties, and/or business managers. � Identify and lead, as assigned, resources and communications to facilitate work completion. 4. Provide technical guidance, training, and work direction to less experienced system engineers � Demonstrate technical proficiency in development and implementation of medium and complex systems and/or computing infrastructure through ability to guide others. � Strong learning competency and ability to teach others. � Advanced troubleshooting and problem solving capabilities 5. Assist other IT team members in understanding policies, operating procedures, and responsibilities � Mentor and train new IT team members to assist them in orientation to policies, procedures, and responsibilities. � Provide ongoing mentorship and support for questions, problems, and ideas. � Serve as an escalation point for system engineers to escalate problems and inquiries requiring further evaluation beyond the associated skill level. 6. Establish and maintain professional working relationships between IT and its customers and constituents. � Represent IT in project and/or business meeting and engagements. � Lead conference calls or visits with vendors/third parties. � Introduce new customers to IT services to assist in familiarizing them with appropriate systems, services, policies, and procedures.

Human Resources Recruiter (OH, Dayton)

Mon, 19 Dec 2011 00:00:00 GMT

Job Summary: The Human Resources Recruiter is responsible for delivering recruiting support throughout the organization. This will be achieved through the development of recruiting plans, employing traditional sourcing strategies and resources as well as developing new, creative recruiting ideas. The Human Resources Recruiter, in conjunction with the Human Resources Consultant, will play a critical role in ensuring we are hiring the best possible talent. Essential Functions: • Complete facets of recruiting cycle to assist HR Consultants. Responsibilities include posting positions (internally and externally), screening and reference checking. • Develop a pool of qualified candidates in advance of need. • Research and recommend new sources for active and passive candidate recruiting. • Build networks to find qualified passive candidates. • Post openings in newspaper advertisements, with professional organizations, and in other position appropriate venues. • Utilize the Internet for recruitment. --Post positions to appropriate Internet sources. --Improve the company website recruiting page to assist in recruiting. --Research new ways of using the Internet for recruitment. --Use social and professional networking sites to identify and source candidates. • Attend career fairs for recruiting and company recognition. • Review applicants to evaluate if they meet the position requirements. • Conduct prescreening interviews. • Assist in performing reference and background checks for potential employees. • Perform any other job related instructions as requested, with reasonable accommodation.

VP Medicare Medicaid Eligibles (OH, Dayton)

Thu, 15 Dec 2011 00:00:00 GMT

Job Summary:   The VP Medicare Medicaid Eligibles will assist the Senior VP Health Services in creating and leading the CareSource Medicare Medicaid Eligibles (MME) Program. He/she will assist with formulating and implementing strategy, responsible for the MME “business” (e.g., design, profit and loss), including contributing to the MME clinical strategy, operations/operational workflows, network development, systems, personnel oversight, and integration of the MME program within CareSource’s suite of services. He/she will work closely with the Senior VP Health Services to define the program as well as incorporate new/emerging opportunities. The individual will work closely with the department heads to ensure operational processes are properly developed and managed and the appropriate priority is assigned as they relate to the overall MME strategy and CareSource business plan.   The individual will focus heavily on ensuring that regulatory and auditing requirements/ initiatives related to the MME program are in compliance.

Essential Functions:

·         Assist the Senior VP Health Services with strategy and program design

·         Network development, including non-traditional payment models

·         Maintain integrity, operations, personnel

·         Develop team structure (design) and staff accordingly

·         Identify market trends and issues, assess competitive environment and form strategic plans for program

·         Lead the development of processes to meet the business requirements of the MME program

·         Actively work with Health Services Directors and Managers in the ongoing oversight of operational procedures as they relate to the MME program

·         Responsible for development and maintenance of documentation related to workflow and process

·         Oversee and control process changes ensuring regulatory compliance and business goals are met

·         Lead the process of implementing new or revised processes and projects

·         Lead the risk assessment associated with any changes in processes

·         Monitor and report on performance improvement via interacting with the various departmen

Enrollment Analyst (OH, Dayton)

Thu, 15 Dec 2011 00:00:00 GMT

Job Summary: To establish and maintain enrollment information on plan members in accordance with established policies and procedures.

Essential Functions:

Ensure proper eligibility status is updated in Facets and Express Scripts

Track newborns and mothers utilizing Microsoft Excel

Coordinate with internal departments and ODJFS to ensure member eligibility is correct

Retro-term or void eligibility spans when advised by the State of retroactive eligibility changes

Assign PCP’s to members with no PCP selected following the reconciliation of monthly State enrollment tape

Enter retro PCP changes as appropriate

Investigate and enter TPL/COB information obtained from state eligibility information or claims staff daily

Initiate mass PCP changes as directed by Provider Relations as a result of provider termination

Modify enrollment spans based on State direction concerning extension of eligibility, “child in custody,” “continuity of care,” “just cause deferrals,” inpatient deferments, waiver, adoptions, and level of care deferment, Medicare recipients, Incarcerations

Perform any other job related instructions as requested, with reasonable accommodation

Internal Auditor (OH, Dayton)

Mon, 12 Dec 2011 00:00:00 GMT

Job Summary:        Perform professional internal auditing work. Work involves conducting performance, operational, financial and/or compliance audit projects; providing consulting services to the organization’s management and staff; and providing input to development of the annual internal audit plan. Maintain all organizational and professional ethical standards. Work under limited supervision with moderate latitude for initiative and independent judgment.

Essential Functions:

·         Assist in identifying and evaluating the organization’s audit risk areas and provide input to the development of the risk-based annual internal audit plan.

·         Perform audit procedures, including identifying and defining issues, developing criteria, reviewing and analyzing evidence, and documenting client processes and procedures.

·         Conduct interviews, review documents, develop and administer surveys, compose summary memos, and prepare working papers.

·         Identify, develop, and document audit issues and recommendations for improvement using independent judgment concerning areas being reviewed.

·         Communicate or assist in communicating the results of audit and consulting projects via written reports and oral presentations on a timely basis to management.

·         Develop and maintain productive team-oriented client and staff relationships through individual contacts and group meetings.

·         Pursue professional development opportunities, including external and internal training and professional association memberships, and share information gained with co-workers.

·         Represent internal auditing on organizational project teams and at management meetings.

·         Execute internal audits as defined by the Director of Internal Audit and the Audit Committee.

·         Document and test risks and controls inherent in the Financial Statement processes/cycles (e.g., Expenditures/AP cycle, Revenue/AR cycle, etc.)

·         Perform any other job related instructions as requested, with reasonable accommodation.

Director, Provider Lifecycle Management (OH, Dayton)

Mon, 05 Dec 2011 00:00:00 GMT

Job Summary: Responsible for optimal network service and provider satisfaction in Ohio and Michigan as it relates to provider lifecycle management to include onboarding and orientation process, provider data maintenance, provider directory, provider data extracts, provider satisfaction and overall provider data quality. Responsible for proactive analysis of internal operational, service and performance metrics, provider data reports, provider surveys etc., and proactively initiate performance improvement activities across the organization to achieve service and satisfaction goals.

Essential Functions:

Develop Provider Service Strategy and program on an annual basis and monitor key metrics to ensure optimal service and satisfaction

Manage Provider Lifescycle process to include the following

New Provider Onboarding Process

Provider Orientation

Provider Data Maintenance

Provider Directory and Other Provider Extracts

Provider Satisfaction

Provider Data Quality

Initiate and manage Continuous Process Improvement across organization to achieve provider satisfaction and service goals

Initiate and implement automated solutions to ensure optimal data quality

Ensure that all Network Operations Policies and Procedures are in place, are up to date, are consistent across department and CareSource and are compliant with all legal, Federal, State and Accrediting standards

Ensure compliance with Model Audit Rules, State, Federal and Accrediting Agencies for all elements related to Providers

Initiate, analyze and act on key data points on an ongoing basis to ensure optimal provider satisfaction and service goals and other operational goals defined in Provider Service Strategy and Program

In collaboration with VP, Network Operations construct and monitor Network Operations Business Plan and Quarterly Key Metrics

In collaboration with Contracting, Credentialing and External Relations, formulate agendas and conduct Network Operations Staff Meetings

Director, Clinical Quality Improvement (OH, Dayton)

Thu, 01 Dec 2011 00:00:00 GMT

Job Summary:    The Director, HEDIS (Health Effectiveness Data Information Set) Operations is responsible in conjunction with the Senior Medical Director, Senior Vice President, Health Services, and Chief Medical Officer for developing, coordinating, and implementing a comprehensive, enterprise wide HEDIS strategy, including implementation of enterprise wide HEDIS quality initiatives within the health plan; to include indicators for monitoring and evaluation of HEDIS quality operations and measures and State performance and bonus measures. Directs the HEDIS quality management program activities throughout the functional areas of the health plan and provides education in the area of HEDIS quality management. Collaborates with the state and federal regulatory agencies on HEDIS quality initiatives and State performance and bonus measures. Provides leadership in the accreditation efforts for the health plan in conjunction with the Medical Director and Health Plan Management.

Essential Functions:

·         Establishes HEDIS program objectives and annual goals in conjunction with the Senior Medical Director, Senior VP, Health Services, and the Chief Medical Officer

·         Directs implementation of the comprehensive HEDIS quality management program

·         Promotes plan-wide understanding, communication, and coordination of the HEDIS quality management program

·         Trends HEDIS quality data and develops aggregate and individual plan reports as indicated

·         Develops HEDIS quality management reports in conjunction with the data Informatics team

·         Analyzes validity of HEDIS quality management data/reports in conjunction with the Informatics team

·         Directs and collaborates with Regulatory and Care Management staff with all activities related to State performance and bonus measure achievement

·         Directs on a quarterly basis reporting of all HEDIS quality initiatives/results and State performance and bonus measures to all appropriate committees

·         Develops, designs, implements and evaluates HEDIS activities including reporting and coordination of the quality focus studies and other indicators of quality of care/service

·         Coordinates development, implementation, and evaluation of continuous quality improvement action plans for the HEDIS qua

BI Analyst Programmer (OH, Dayton)

Tue, 08 Nov 2011 00:00:00 GMT

Job Summary: Develop reporting that meets the information needs of the organization. Work

Job Summary: Develop complex reporting products that meet the information needs of the organization as well as external partners. Work with the business areas to identify and implement opportunities for process improvement that impact performance, quality, and/or profit through the delivery of business intelligence and/or reporting products. Assist in the design of Business Intelligence products for both internal and external use.

Essential Functions:

Develop complex automated reporting products that meet the internal and external information needs of the organization.

Assist in the design of Business Intelligence products for both internal and external use.

Participate in testing activities as needed.

Responsible for adhering to proper coding standards and IT change control process.

Generate graphics that effectively describe, explore and summarize information for communication to appropriate parties.

Incorporate critical thinking skills and judgment in the process to determine best course of action for each inquiry/problem.

Investigation of data that shows a pattern or indicates a significant variation from expected.

Perform any other job related instructions as requested, with reasonable accommodation.

Human Resources Recruiter (OH, Dayton)

Thu, 03 Nov 2011 00:00:00 GMT

Job Summary: The Human Resources Recruiter is responsible for delivering recruiting support throughout the organization. This will be achieved through the development of recruiting plans, employing traditional sourcing strategies and resources as well as developing new, creative recruiting ideas. The Human Resources Recruiter, in conjunction with the Human Resources Consultant, will play a critical role in ensuring we are hiring the best possible talent. Essential Functions: • Complete facets of recruiting cycle to assist HR Consultants. Responsibilities include posting positions (internally and externally), screening and reference checking. • Develop a pool of qualified candidates in advance of need. • Research and recommend new sources for active and passive candidate recruiting. • Build networks to find qualified passive candidates. • Post openings in newspaper advertisements, with professional organizations, and in other position appropriate venues. • Utilize the Internet for recruitment. --Post positions to appropriate Internet sources. --Improve the company website recruiting page to assist in recruiting. --Research new ways of using the Internet for recruitment. --Use social and professional networking sites to identify and source candidates. • Attend career fairs for recruiting and company recognition. • Review applicants to evaluate if they meet the position requirements. • Conduct prescreening interviews. • Assist in performing reference and background checks for potential employees. • Perform any other job related instructions as requested, with reasonable accommodation.

Director, Care Management - Cleveland (OH, Cleveland)

Thu, 03 Nov 2011 00:00:00 GMT

Job Summary: Responsible for planning, directing and coordinating the care management activities, policies and program goals. Assumes responsibility for the overall functions and professional growth of the care management department by contributing to policies, programs, accreditation, medical cost, and quality activities. Assumes responsibility for the fiscal and regulatory management of the department’s programs. Assumes the lead role in ensuring member engagement and satisfaction.

Essential Functions:

Develop, implement, monitor, and/or revise case management policies, procedures and goals as needed or required

Design care management programs to reduce cost and improve the quality of care for members

Manage the benefits for CareSource members

Ensure compliance with all statutes and regulations.

Ensure meeting or exceeding appropriate clinical requirements of the ODJFS bonus program for CareSource

Develop case management programs utilizing NCQA standards

Direct Complex Case Management program

Collaborate with the Disease Management and Wellness program staff ongoing and share/implement best practice

Develop, implement, monitor, and/or revise all government programs

Develop and sustain community service agency relationships

Lead pertinent team projects ongoing

Chair the Care Management Committee

Lead the Case Management certification activities

Participate in the Ohio Nurses Association Continuing Education Provider Unit activities

Develop and monitor care management budgets ongoing; describe variance detail monthly

Participate and represent CareSource externally with speaking engagements, State and regional committee work

Update care management program description documents annually

Evaluate care management effectiveness ongoing and conduct outcome evaluation on all programs ongoing

Coordinate member satisfaction survey activities

Conduct a care management program evaluation annually

Create (annually) and monitor (quarterly) the care management program work plan

Perform any other job related instructions as requested, with reasonable accommodation.

Procurement Coordinator (OH, Dayton)

Mon, 17 Oct 2011 00:00:00 GMT

Job Summary: Assist with managing the corporate purchasing function and associated processes to ensure the Company is procuring materials, equipment, and services with the highest level of quality and in the most cost efficient manner. This role will assist in the development and implementation of a diverse and multifaceted supply chain for CareSource. Essential Functions: • Identify and implement procurement opportunities with business owners to reduce overall corporate spend on various high dollar expenses such as printing, consulting, equipment expenses, software support agreements, etc. • Assist in the Implementation of corporate policies and procedures to guide Investment Proposal (IP), Request for Proposal (RFP) and procurement activities company-wide. • Monitor compliance of business owners with preferred supplier expenditures. • Establish and maintain partnerships with internal customers and suppliers for maximum value and policy compliance. • Assess vendor contract performance by regularly reviewing vendor effectiveness, efficiency and quality. • Perform prospective vendor assessments including financial stability and customer reference checks. • Daily activities include accurate and timely Vendor maintenance, Purchase Order (PO) entry, Invoice Resolution, filing of contracts, POs, etc. and Ordering Supplies. • Adhere to vendor conflict of interest and gift policies. • Perform any other job duties and projects as requested with reasonable accommodation.

Operations Specialist (OH, Dayton)

Mon, 26 Sep 2011 00:00:00 GMT

Job Summary:

With support of Team Lead, schedules and executes all required batch processing, scripting, and solution monitoring. Assignments are comprehensive and complex and entail interactions between departmental elements and may involve other areas of the organization at various levels of management. Documents Operations procedures. Develops and produces Operations performance metrics. Functions as a strong technical member of the operations team. Trains other team members. Performs daily Operations tasks when needed.

Director Data Management (OH, Dayton)

Wed, 07 Sep 2011 00:00:00 GMT

Job Summary: The Director, Data Management will support and lead the data warehouse system capabilities and services to enable decision support across the organization. This Director will also support the proactive transformation initiatives in the use of Data Management for optimizing analytics across the company.

The Director will direct, in close coordination with the Director, BI Services, all data management efforts for the company including data warehousing, standardization, databases, documentation, knowledge repository, policies and procedures and governance of all Caresource related issues and developments as it relates to data management. Another key component of this job is responsibility for all State and Federal data submissions including encounter data, CAMS, UMDB, etc.

Essential Functions:

Drive the strategy, development and implementation of the enterprise Data Warehouse and Data Management capabilities throughout the organization.

Work closely with management to prepare and execute data management plans to manage projects from beginning to end

Develop annual budgets and schedules to meet Caresource needs. Set priorities for areas of responsibility and allocates staff as needed to meet departmental/company goals.

Responsible for managing, planning and coordinating the activities of the Data Management group.

Manage complex initiatives that significantly affect business results, and require a large degree of cross-functional participation/coordination.

Work with business areas and IT to ensure integrity and proper integration for all sources of enterprise data.

Collaborate with business partners and senior leadership to prioritize data-driven projects, and to provide quality information to support business processes.

Manage and oversight of the Data Management (DM), and data warehousing (DWH) functions:

Develop, designs, implements and maintains Caresource Enterprise data warehouse (CSEDW)

Develop, designs, implements and maintains all Caresource databases

Develop, designs, implements and maintains all Caresource common data dictionaries and meta data

Oversee data modeling and data sourcing for all data moving into, out of, and within CareSource.

o   Manage data collection rule documentation, modifications, and communications of standards, policies and procedures

o   Manage the data collection process up to and including preparing the data for QA and extract to internal and external entities.
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Distribution Processing Coordinator (OH, Dayton)

Wed, 07 Sep 2011 00:00:00 GMT

Job Summary:   Responsible for all incoming and outgoing mail service functions, including managing shipping/receiving function, remote office support, facilities services support, document destruction and retention, fulfillment services and document scanning. This position must be able to develop reports that track volume and usage of these services. Responsibilities also include working under limited supervision using standardized practices, providing information and tracking budget expenditures. Utilization of resources from other work units may be required to perform the job’s functions.

Essential Functions:

Receive, open, sort, and distribute incoming mail to all departments and remote offices. Pick up outgoing mail, Fed Ex, and UPS from all floors and process. Process registered, certified and overnight mail

Manage schedule, ship, receive, off-load products and goods and deliver as part of service to the building. Work with departments to accommodate their requests

Maintain equipment, tools, supplies and work area to ensure a safe and productive working environment

Operate and maintain mailing equipment such as postage machine, letter opener and folder/inserter machine

Manage the tracking and ordering of office supplies for entire company.

Establish service levels to support copier program. Perform functions related to a high volume copy center operations (copy, printing, fold/insert, punching and compiling of books and literature for internal and external projects.

Operate copier management including stocking toner and paper, responding to 1^st level repair calls, coordinating outside calls and recording meter readings

Create reporting to track various activities related to department functions including volume tracking, postage meter readings, productivity and special requests

Coordinate off-site document retention and retrieval. Maintain document destruction records and request destruction of expired documents.

Assist with facilities support including internal moves, AV equipment requests, room set-ups and reconfigurations.

Open, sort, batch and scan business documents for internal processing as required

Operation of light equipment (forklift) may be required

Perform any other job related instructions as requested, with reasonable accommodation

CareAdvance Coordinator (OH, Dayton)

Mon, 01 Aug 2011 00:00:00 GMT

Job Summary: Under the direction of the Care Advance Clinical Manager, this individual will be responsible for building and maintaining care plan guidelines and assessments, conduct workgroups to gather and establish requirements workflow and content editor within the Care Advance system.

This individual will also be responsible for testing all new forms, letters, campaigns, concepts care plans and assessments.

Essential Functions:

·         Plan and implement new software enhancements including testing and training

·         Leads systems requirements definition, design, testing, training and implementation support

·         Facilitate workgroups to collect and document business requirements for content

·         Proficient on clinical Care Management workflow to ensure accurate and completeness of members through care management process

·         Responsible for coordination and oversight of system content development and maintenance in the computer systems

·         Cross-functional collaboration to build system content, such as concepts, forms, letters, assessments and care plans

·         May assist in departmental training programs and lunch-and-learns, as needed

·         Will perform in-depth quarterly testing of previously defined errors and assess if errors and problems have been satisfactorily resolved

·         Responsible for testing configuration changes of the system

·         Perform any other job related instructions as requested, with reasonable accommodation

Senior Project Manager (OH, Dayton)

Fri, 15 Jul 2011 00:00:00 GMT

Job Summary: This position exists to manage the projects in various portfolios derived from the company’s three year rolling business plan. The incumbent will work closely with senior leadership to ensure projects are properly funded, resourced and managed. Supports several midsize-to-large projects. The incumbent has familiarity with, and demonstrated understanding of, the enterprise's business and technical architectures. Essential Functions: • Identify necessary management structures for projects, and secure the management involvement required. • Oversee and control any external resources contracted to the project. • Drive proper project chartering and setup. • Maintain strategic alignment of projects by analyzing charters and reviewing with management decision makers. • Forecast internal resource capacity by tracking the progress of projects across the portfolio. • Perform team management, driving motivation, collaboration and performance. • Estimate project costs and manage the budget (includes related scope control). • Define and drive "rightsized" project management processes (especially, supporting quality assurance). • Track and report on project metrics and benefits. • Responsible for managing the project throughout its lifecycle. • Incorporates effective change and risk management controls.

Application Developer � Applications (OH, Dayton)

Mon, 09 May 2011 00:00:00 GMT

Job Summary:        The application developer’s role is to design, code, test, and analyze software programs and applications. This includes researching, designing, documenting, and modifying software specifications throughout the production lifecycle. The software developer will also analyze and amend software errors in a timely and accurate fashion and provide status reports where required. This role will work closely with SAQ and team members to understand business and functional requirements that drive technical design and quality solutions. Responsibilities may also include mentoring Jr. Developers as needed and working with Sr. developers on component and architecture design. Must have experience in systems analysis, design and a solid understanding of development, quality assurance and integration methodologies.

Essential Functions:

Strategy & Planning

·         Assist other developers, analysts, and designers in conceptualizing and developing new software programs and applications.

·         Plan phases of the software development life cycle (SDLC) for a variety of projects.

·         Assist in the preparation and documentation of software requirements and specifications.

·         Research and document requirements of software users.

Acquisition & Deployment

·         Conduct research on emerging application development software products, languages, and standards in support of procurement and development efforts.

·         Recommend, schedule, and perform software improvements and upgrades.

Operational Management

·         Consistently write, translate, and code software programs and applications according to functional/technical specifications that meet business requirements.

·         Run and monitor software performance tests on new and existing programs for the purposes of correcting errors, isolating areas for improvement, and general debugging.

·         Administer critical analysis of test results and deliver solutions to problem areas.

·         Generate statistics and prepare and write reports for management and/or team members on the status of the programming process.

·         Assist in the development and maintenance of user manuals and guidelines.

·     &

Director, Pharmacy (OH, Dayton)

Mon, 18 Apr 2011 00:00:00 GMT

Job Summary:   Oversee and direct clinically focused areas and operations of Pharmacy Department related to Medicare and Specialty Pharmacy business. Assist the Vice President of Pharmacy in formulating and administering related organizational goals, policies and procedures to ensure compliance with all statutes and regulations, both State and Federal. Policy and procedure development will include Specialty Pharmacy Operations and Medicare Part D. Participate in strategic development activities consistent with mission, philosophy, objectives and goals.

Essential Functions:

·         Co-chair the Specialty Pharmacy Work Group driving development of necessary medical policies and overall specialty pharmacy strategy.

·         Create tactical approach for pharmaceutical contracting within the specialty pharmacy arena.

·         Serve as primary operational contact with the designated Specialty Pharmacy preferred vendor(s).

·         Maintain Pharmacy call center statistics within regulatory compliance for the Specialty Pharmacy

·         Review and implement new technological tools and foster team concept with internal and external constituencies.

·         Assist in development and execution of pharmacy programs to meet Pharmacy department’s clinical, operational and financial goals.

·         Provide oversight for Medicare Part D pharmacy program.

·         Set and properly execute all Medicare Part D operational requirements as defined by CMS

·         Serve as primary contact for the delegated entity managing our Medicare Part D business.

·         Integrate and leverage relationships with other areas within CareSource, such as Care Management, Member Services, etc.

·         Represent Pharmacy on company-wide committees relating to both operational, medical management and financial oversight.

·         Determine minimum workflow standards.

·         Participate in employee evaluations and maintain discipline as needed.

·         Contribute to determining operational and staffing needs of the Pharmacy department to meet requirements as set by CMS.

·  &

Sr Application Developer - Applications (OH, Dayton)

Thu, 07 Apr 2011 00:00:00 GMT

Job Summary:        The senior application developer’s role is to design, code, test, and analyze software programs additionally this role will be required to mentor and help architect system design through coordination with the business and IT. This includes researching, designing, documenting, and modifying software specifications throughout the production lifecycle. The senior application developer will also analyze and amend software errors in a timely and accurate fashion and provide status reports where required. Additionally this role will help coordinate work between management, Project managers and SQA to assist in presenting technical solutions to the organization.

Essential Functions:

Strategy & Planning

·         Mentor other developers, analysts, and designers in conceptualizing and developing new software programs and applications.

·         Plan phases of the software development life cycle (SDLC) for a variety of projects.

·         Assist in the preparation and documentation of software requirements and specifications.

·         Research and document requirements of software users.

·         Assist and contribute to the Architectural Council on all software solutions designed or purchased at CareSource.

·         Assist PM/SQA and other groups coordinate developers and projects to completion.

·         Clarify and drive team goals on a technical level making sure that the solutions proposed and designed are in line with the department and CareSource vision.

Acquisition & Deployment

·         Conduct research on emerging application development software products, languages, and standards in support of procurement and development efforts.

·         Recommend, schedule, and perform software improvements and upgrades.

·         Assist the Architectural Council with technical knowledge regarding emerging technologies to help drive strategy.

·         Assist management with resource and release planning.

Operational Management

·         Consistently write, translate, and code software programs and applications according to specifications.

·         Define architecture and d

Director Application Development (OH, Dayton)

Tue, 15 Mar 2011 00:00:00 GMT

Job Summary: Define, implement and maintain the company’s application portfolio environment. Set vision, direction and execution for business applications. Develop strategy and high-level implementation plan for the delivery of new and existing applications. Provide strategic plan for continual competitive enhancements to application portfolio. Ensure that applications perform and deliver desired business results. Essential Functions: 1. Accountable for acquisition, development, delivery and third tier support of application software • Set vision, direction and execution for business applications • Develop strategy and high-level implementation plan for the delivery of new applications • Validate the business proposition associated with new application initiatives • Provide strategic plan for continual competitive enhancements to our application portfolio • Employ best-practice software release management processes • Ensure software projects are completed according to development methodologies, product specifications, and are properly documented • Direct and lead the department as part of a corporate-wide software and automation validation program • Provide technical oversight to ensure the proper architecture and product performance is delivered • Provide leadership in dealing with 3rd party integration requirements • Assess the technology platform to ensure reliability, availability, security, cost and performance, justification, regulatory, infrastructure and short/long term planning • Develop technical, project management and leadership skills of IT professionals 2. Establish and maintain professional working relationships between IT and its customers and constituents. • Represent IT in project and/or business meeting and engagements • Participate in conference calls or visits with vendors/third parties • Participate in departmental meetings/activities and contributes to a team environment • Foster relationship management through communication; to include, business decisions required by technology, development status, problems and issues, project status and success 3. People management of personnel • Set performance goals and objectives • Provide supervision and review of work products • Provide regular and effective feedback on performance 4. Oversight of application projects from inception/design through implementation. • Plan and manage assigned projects • Assure quality application programming, analysis, and specification development • Organize and direct people and projects • Plan, design and document processes and workflows 5. Provide technical guidance, training, and work direction „X Guide team members in the assigned areas of responsibility • Mentor and teach team members in order to improve team technical and business strengths • Direct team in troubleshooting and problem solving 6. Leverage personne

Generic Posting for Fact Finding Phone Screens (OH, Dayton)

Thu, 10 Mar 2011 00:00:00 GMT