The Risk Adjustment Coding Auditor II is responsible for performing over reads of vendor ICD 10 coding, reviewing provider documentation supplied to them, and diagnostic codes assigned by vendor. This job is full time, remote. Essential Functions Meets assigned volume metrics Validates the accurateness of ICD 10 codes assigned by the vendor Tracks the trends and reports o

The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members. Researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for o

The Operations Specialist II provides analytical support and leadership for project impacting Claims and key internal Claims projects. Essential Functions Represent claims on cross functional project work teams Submit, monitor and prioritize IT tickets for the Claims department Review special projects and identify issue trends and potential resolutions Assist with Onbase

The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members. Researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for o

The Customer Care Specialist I assists members or providers with routine service inquiries. Must live in Ohio Starting pay $18 Training schedule Must be able to train FULL TIME hours 8am 4 30p M F Essential Functions Resolve member or provider routine service inquiries; examples include claims processing, member benefit education, contracting and credentialing requests, e

The Operations Specialist II provides analytical support and leadership for project impacting Claims and key internal Claims projects. Essential Functions Represent claims on cross functional project work teams Submit, monitor and prioritize IT tickets for the Claims department Review special projects and identify issue trends and potential resolutions Assist with Onbase

The Member Health Assessor engages with the member to establish an effective, professional relationship with primary responsibility to conduct a standardized Health Risk Appraisals (HRA). Essential Functions Verify eligibility, previous enrollment history, demographics and current health status of each member prior to outreach Engage the member to gather information to as

The Director, Quality Risk Adjustment Operations manages the operational execution of insourced and outsourced risk adjustment programs for all products MA/MMP/DSNP (Hierarchical Condition Category/HCC), Marketplace (Department of Health & Human Services/HHS), Medicaid (CDPS Rx), and expansion products by developing and implementing operational processes and program manag

The Distribution and Processing Services Specialist I is responsible for all incoming and outgoing mail service functions including processing registered, certified, and overnight mail. This position works full time in office at our Dayton HQ. Essential Functions Receive, open, sort, and distribute incoming mail to all departments, multiple buildings in Dayton and regiona

The Vice President, Market Operations is responsible for developing the overall market program strategy and business objectives; lead the alignment and collaboration to establish CareSource as the industry leader in member and provider engagement, member and provider experience, and plan management in the market. Essential Functions Develop the overall market program stra

The Vice President, Market Chief Medical Officer has accountability for ensuring that local health plan, CareSource initiatives focusing on clinical excellence, quality improvement, appropriate inpatient and outpatient utilization, affordability, health system transformation including provider network, compliance with regulatory mandates, growth and other focused improvem

The Compliance Analyst II position is a professional compliance role responsible for supporting the Compliance Program by collaborating and overseeing high risk areas to ensure that the compliance program is effective and efficient in identifying, preventing, detecting, and correcting noncompliance. Essential Functions Provide Compliance Program support with audit and mon

The Sales Coordinator II, in collaboration with team members and leadership, supports the sales strategy and sales enrollment initiatives to ensure annual sales goals are successfully achieved. Essential Functions Work with Leadership to provide support for the internal systems tracking of sales and commissions Manage daily onboarding of agents including validation of com

The Life Services Life Coach provides one on one coaching and development for participants in the Life Services program as defined by member needs both urgent, immediate, and long term to prepare members for employment or education programs and assist them with social determinants of health (SDOH) needs. Essential Functions Complete required assessments by gathering infor

The Operations Specialist II provides analytical support and leadership for project impacting Claims and key internal Claims projects. Essential Functions Represent claims on cross functional project work teams Submit, monitor and prioritize IT tickets for the Claims department Review special projects and identify issue trends and potential resolutions Assist with Onbase