Current Job Opportunities

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 JobTitleCityStateJobType
AR-CT-3833Manager, Medical ManagementLittle RockAR 
AR-CT-3838Care ManagerLittle Rock/Springdale/FayettevillAR 
AZ-CT-3790Director, Medical Management OperationsTempeAZ 
AZ-CT-3866Director, Network and Payment Innovation   
CA-CT - 3848Senior Care Manager Woodland HillsCA 
CA-CT-3779Director, Medical Management - TWO POSITIONSRancho CordovaCA 
CA-CT-3832VP, Actuarial Services & Risk Management    
CA-CT-3837Director, EnrollmentRancho CordovaCA 
FL - CT- 3862Director, UM Maitland TE
FL-CT- 3825Manager, UM - DentalTampaFL 
FL-CT-3432Director, Case ManagementTAMPA or SUNRISE FL 
FL-CT-3711Director, Medicare STARSSunriseFL 
FL-CT-3749Supervisor, UMTAMPAFL 
FL-CT-3757Manager, UMFt Lauderdale FL 
FL-CT-3766Manager, UMMaitlandFL 
FL-CT-3774Manager of Quality    
FL-CT-3791Case Manager II Maitland/OrlandoFL 
FL-CT-3868MANAGER, UM    
GA-CT- 3765CARE MANAGER II AtlantaGA 
GA-CT-3389Data Analyst III or IVAtlantaGA 
 
Job ID:AR-CT-3833
Job Title:
Manager, Medical Management
Rate:
Primary Skills:
Description:
 


 


 


Manager,
Medical Management- Little Rock, AR


Join an
organization that truly values their RN’s and is known for exceptional programs
of care and quality.


Manager is responsible for managing a complete Medicare Advantage program
of medical management which includes the functions of utilization management
and case management.




Implement changes to medical service functions and
performance in relation to Medicare guidelines, company mission, philosophy
objectives and policies




· 
Manage budgets and forecast for strategic planning and key initiatives
and balance current future needs effectively 




· 
Research and incorporate best practices into operations




· 
Assure compliance of work processes with Medicare Advantage and CMS
regulations




· 
Responsible for the statistical analysis of utilization data




· 
Participates in NCQA accreditation of the Plan.




Qualifications:

-  Bachelor's degree in Nursing or
equivalent experience.


-3+ years combined nursing, quality
improvement and managed care experience.


-Proficiency in Microsoft
Applications, preferably excel.


-Previous experience as a lead in a
functional area, managing cross functional teams on large scale projects or
supervisory experience including hiring, training, assigning work and managing
the performance of staff.


-Previous experience managing
Medicare Advantage programs preferred. 



License/Certification: RN license.
 
    
 
Job ID:AR-CT-3838
Job Title:
Care Manager
Rate:
Primary Skills:
Description:
CARE MANAGER – 2 office based position in Little Rock-  1 remote each in Fayetteville and Springdale (work in your home office)

GROWING national company offers GREAT benefits and training.

Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care
Develop, assess and adjust, as necessary, the care plan and promote desired outcome
Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options
Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients
Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs
Provide patient and provider education
Facilitate member access to community based services
Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan
Actively participate in integrated team care management rounds
Identify related risk management quality concerns and report these scenarios to the appropriate resources
Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems
May perform some home visits to members

Qualifications:
Education/Experience: Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community setting. Knowledge of managed care preferred. Licenses/Certifications: Current AR RN license.
 
    
 
Job ID:AZ-CT-3790
Job Title:
Director, Medical Management Operations
Rate:
Primary Skills:
Description:
Director, Medical Management Operations - Tempe
Rapidly expanding market - national healthcare enterprise
Innovative, process- driven leader will be called on to lead Medical Management process improvement initiatives to reduce medical costs, reduce administrative costs, and improve member quality.

Assist Medical Management clinical leadership team to establish baseline and target metrics for key business/functional processes

Develop and analyze reports across multiple systems to analyze key business drivers and trends in order to develop appropriate mitigation initiatives

Collaborate and provide analytical support to Medical Management clinical leadership to facilitate the development, implementation, and evaluation of performance improvement initiatives.

Develop processes to increase effectiveness and efficiency, while ensuring compliance with NCQA and contract requirements

Lead end to end process evaluation from medical management processes to associated claims payment

Develop and facilitate implementation of business processes to leverage technology to increase effectiveness and efficiency; integrating multiple systems to maximize outcomes

Develop and implement a consistent methodology to evaluate pilots, processes, and programs

Provide leadership and direction to Preauthorization Workforce Management team

Qualifications:
Bachelor's degree (Master’s degree is a plus)
Not required to be a clinician but need to have deep understanding of the clinical aspects as well as the operational/audit.
 7+ years of related medical management, operations, analysis, and managed care experience.
Advanced knowledge of Excel and Access.
 Previous leadership and staff development expertise.
 
    
 
Job ID:AZ-CT-3866
Job Title:
Director, Network and Payment Innovation
Rate:
Primary Skills:
Description:
 
    
 
Job ID:CA-CT - 3848
Job Title:
Senior Care Manager
Rate:
Primary Skills:
Description:
 
    
 
Job ID:CA-CT-3779
Job Title:
Director, Medical Management - TWO POSITIONS
Rate:
Primary Skills:
Description:
Director, Medical Management - CA - need 2 for new contract!
New region opening and it's a GREAT opportunity to bring your own ideas and creativity.
Strong leaderhsip support of programs of care management.  Director will work closely with the Medical Informatics team to identify trends that need to be addressed with program management.
- Responsible for Care Management clinical inter-rater reliability and monitoring important aspects of care.
- Effectively manages the activities of staff providing leadership and guidance.
•  Interviews, recommends for hire, and evaluates staff, and counsels and confronts unsatisfactory performance promptly and fairly and administers corrective action.
•  Identifies department goals and objectives, develops and communicates action plans through regular staff meetings and other communications, uses team approach to problem solve and sets clear expectations.
•  Identifies training needs and develops and participates in staff training. Provides a challenging and supportive environment and delegates appropriately. Seeks additional training opportunities through outside sources.
•  Analyzes work plans developed by subordinate managers and monitors the status of their work in relation to the overall schedule requirements.
•  Develops monitoring systems and measurements and exhibits a customer service philosophy.
•  Manages statistical and qualitative information concerning patient outcomes and physician/hospital practice patterns in accordance with health plans’ utilization standards.
•  Intervenes with hospital or physician contractors to examine cases to ensure methods for meeting these utilization standards while maintaining precedent for quality of case standards.
•  Determines and enforces - through functional groups - medical management requirements in accordance with real company needs, based on current regulations and state-of-the art product development.
•  Organizes and promotes medical management functions.
•  Evaluates and develops improved techniques for the control of quality and reliability.
•  Plans and develops improved techniques for the control of health care costs.
•  Plans, on a quarterly or longer basis, the overall use of resources.
•  Provides information and advice to higher level management related to medical management.
Qualifications:
Education/Experience: Bachelor’s degree in Nursing or equivalent required; Master’s degree in Health Services Administration or equivalent desired. Five years clinical experience in an acute care setting. Four years experience in quality management/improvement in a health care setting. Two years work experience in a managed care environment. Five years management experience in a health care setting. Three years medical management experience in an HMO setting desired
License/Certification: Must have and maintain current valid and unrestricted Registered Nursing (RN) license. Valid state driver’s license
 
    
 
Job ID:CA-CT-3832
Job Title:
VP, Actuarial Services & Risk Management
Rate:
Primary Skills:
Description:
 
    
 
Job ID:CA-CT-3837
Job Title:
Director, Enrollment
Rate:
Primary Skills:
Description:
Director, Enrollment-  Rancho Cordova
Our health plan client is seeking a tech –savvy, engaging leader who thrives on process improvement and excels in a production –drive atmosphere.
Excellent career potential!
Director will provide strategic direction for all enrollment and eligibility functions.
•  Oversee the Eligibility and Enrollment department staff
•  Establish working relationships with external sources with Health & Human Services Commission (HHSC), state enrollment broker and other local state offices
•  Collaborate with internal operations teams to identify efficient solutions to meet business needs related to enrollment and facilitate continued process improvement
•  Establish and maintain liaison relationships with corporate IT to support and facilitate the common goals and objectives related to enrollment and eligibility services
•  Design and test new codes sets and processes for new product implementation to include business rule integration and state contract compliance
•  Manage and establish file interchanges with external vendors and affiliates including the mailhouse
•  Direct resolution to state complaint trends related to enrollment and eligibility
•  Represent the health plan in state MIS meetings
•  Develop and implement a reconciliation process of enrollment and financial records
•  Direct the eligibility load process while coordinating with corporate IS department to resolve issues that arise during the process
•  Coordinate monthly reconciliation process of remittance files by resolving discrepancies in the report

Qualifications:
(Specific enrollment opportunity is not required)
-Bachelor's’ degree in related field or equivalent experience.
- 7+ years of operations experience with large managed care or government programs helpful
- Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
- Must bring a deep understanding of system interface and how data can be translated between systems.
 
    
 
Job ID:FL - CT- 3862
Job Title:
Director, UM
Rate:
Primary Skills:
Description:
Director, Utlization - Medical Management - MAITLAND, FL
Nice opportunity for an experienced leader to be part of a growing team.
                  Generous relocation- excellent analytic tools and support.
- Direct medical management program including UM, case management, QI and credentialing.
- Develop department objectives and implement action plans to achieve objectives.
-  Evaluate and implement changes to medical service functions and performance.
-  Manage budget and forecast for strategic planning and key initiatives.
-  Coordinate with operating departments on research and implementation of best practices.
-  Statistical analysis of utilization data on programs.
-  Participate in NCQA, State, and/or other accreditations of the Plan..
-  Develop effective communication plans with external providers such as hospitals and State agencies.
-  Coordinate with Medical Director to educate and communicate expectations with providers.



Ideal Candidate Profile:

- Bachelor's degree in Nursing, related field, or equivalent experience.
-7+ years of nursing, quality improvement, and management experience in managed care.
-Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
-RN license
-Experience in FL a strong plus
 
    
 
Job ID:FL-CT- 3825
Job Title:
Manager, UM - Dental
Rate:
Primary Skills:
Description:
 
    
 
Job ID:FL-CT-3432
Job Title:
Director, Case Management
Rate:
Primary Skills:
Description:
Director, Case Management - TAMPA

INNOVATIVE health plan truly values their nurses . The Director will be engaged in creating, defining and directing a complete Case Management Program across a diverse population.

This will encompass needs analysis and planning; working with executive leadership to ensure targets are met for the annual operating plan; ensuring compliance with Corporate, State and NCQA standards. Director will be asked to develop and implement methods, policies and procedures to improve the departments efficiency and overall effectiveness.

Exceptional benefit package and growth potential here !

We are interviewing candidates with a Bachelor's degree in Nursing or related field, an RN with at least 5 years of work experience in managed care and acute care settings with complex case management. Previous leadership will be important, including including hiring, training, and managing performance of staff.
 
    
 
Job ID:FL-CT-3711
Job Title:
Director, Medicare STARS
Rate:
Primary Skills:
Description:
Director, Medicare STARS – FT Lauderdale
Newly –created role will provide strategic leadership, guidance and manage the Medicare STARs for the Medicare Plans in the Florida market. 
RELOCATION package- great benefits- wonderful opportunities to grow!
•  Act as a leader and expert of Medicare Stars Program to ensure Healthcare Effectiveness Data and Information Set (HEDIS) and Stars objectives are met to support the overall goals
•  Develop, manage and coordinate clinical and non-clinical HEDIS and Stars-related activities
•  Integrate Stars activities with risk adjustment initiatives.
•  Work closely with various cross-functional teams, locations and departments to improve STARs outcomes for Medicare members
•  Serve as a business resource and subject expert for health plan quality and Medicare operations teams and all internal and external business partners
•  Closely follow CMS guidance and translate into business strategies and tactics
•  Partner with multiple stakeholders and business unit leadership to establish operational objectives and procedures
•  Perform analysis of enterprise-wide data and practices to identify opportunities for improvement at the local and national level
•  Lead cross functional efforts to develop, deploy and manage reporting dashboard.
•  Ensure policies and procedures are compliant with NCQA and CMS guidelines
Qualifications:
- Bachelor's degree in Nursing, Healthcare Administration or related field.
-7+ or more years of experience in managed care operations with emphasis on Medicare
- Must have experience with improving STARs outcomes.
- Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
- Knowledge of Center for Medicare/Medicaid Services, requirements for Special Needs Plans (SNP), Medicare Medicaid Plans (MMP) and NCQA oversight requirements preferred.
 
    
 
Job ID:FL-CT-3749
Job Title:
Supervisor, UM
Rate:
Primary Skills:
Description:
Supervisor, UM - TAMPA
Lead the UM team in all daily operations .  Innovative organization values their RN's and leadership supports their teams.   GREAT benfits include generous TUITION and bonus. 
•Ensure appropriate usage of resources in order to facilitate the UM process
•Ensure compliance within applicable state program guidelines
•Evaluate compliance policies and procedures and analyze/recommend enhancements
•Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting in order to meet external requirements
•Identify opportunities for process improvements necessary to facilitate department functions
•Educate staff as necessary to ensure consistent performance and adhere to standards
•Assist UM Manager and Director with coordinating and facilitating system processes with providers, partners, vendors, and subcontractors as necessary
Qualifications:
Education/Experience: 3+ years of utilization management/quality improvement experience. Working knowledge and understanding of basic utilization management and quality improvement concepts. Previous experience as a lead in a functional area or managing cross functional teams on large scale projects.
License/Certification: Current FL RN license.
 
    
 
Job ID:FL-CT-3757
Job Title:
Manager, UM
Rate:
Primary Skills:
Description:
MANAGER,  QUALITY- Ft.  Lauderdale
(VP, Quality also available)
Strong leadership team with unlimited growth – AMAZING analytic support
Relocation is paid by the employer – it is time to head SOUTH!

Oversee and manage the functions of the quality improvement program. Providing support to staff and communicate with departments and staff to facilitate daily quality improvement (QI) functions.
Review and analyze reports, records and directives.
Confer with staff to obtain data such as new projects, status of work in progress, and problems encountered, required for planning work function activities. Verify data to be submitted in accordance with government program requirements and ensure compliance with state, federal and certification requirements.
Prepare reports and records on work function activities for management.
Oversee the review and analysis of reports.
Evaluate current procedures and practices for accomplishing the assigned work functions objectives to develop and implement improved procedures and practices and to ensure compliance with required standards.
Collaborate with appropriate departments to document, investigate and resolve formal or informal complaints and appeals in accordance with Company and State policies, procedures and requirements.
Monitor and analyze costs and participate in the preparation of the budget.
Qualifications:
Education/Experience: Bachelor’s degree in related field or equivalent experience. 3+ years clinical, quality management or healthcare related experience and 1 year of recent quality improvement and supervisory experience in a healthcare environment, preferably managed care.
Project management experience is a plus. 


 
 
    
 
Job ID:FL-CT-3766
Job Title:
Manager, UM
Rate:
Primary Skills:
Description:
Manager, UM  - Maitland, FL
Exceptional analytic support- award winning programs of care.
This organization is leading the way in integrated healthcare.
Hands on leaders will direct all activity of the UM team.
• Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives.
• Promote compliance with federal and state regulations and contractual agreements.
• Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions.
• Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure.
• Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
• Facilitate on-going communication between utilization management staff and contracted providers.
• Develop staff skills and competencies through training and experience. Available to non-clinical staff as a resource for clinical questions.

Qualifications:
Education/Experience: Bachelor’s degree in related field or equivalent experience. Bachelor’s degree in nursing preferred. 3+ years utilization management and recent nursing experience in an acute care setting particularly in medical/surgical, pediatrics, or obstetrics and management experience. Thorough knowledge of utilization management and clinical nursing. Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
 
    
 
Job ID:FL-CT-3774
Job Title:
Manager of Quality
Rate:
Primary Skills:
Description:
 
    
 
Job ID:FL-CT-3791
Job Title:
Case Manager II
Rate:
Primary Skills:
Description:
CARE MANAGER II - Maitland/Orlando - office -based 
Make a positive impact on members lives by helping them improve their health and access to care.
Great opportunity to join a new team rolling out a new product in Florida.  Supportive manager and unlimited growth-  no "on call" or weekends!  

RN will assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care.

This may include assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options
Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes
Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients
Provide patient and provider education
Facilitate member access to community based services
Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan
Actively participate in integrated team care management rounds
Identify related risk management quality concerns and report these scenarios to the appropriate resources.
Requirements:
RN license in FL
2+ years clinical
1+ year of discharge planning (hospital) or case management in a clinical or health plan setting.  Must have basic computer skills.
 
    
 
Job ID:FL-CT-3868
Job Title:
MANAGER, UM
Rate:
Primary Skills:
Description:
 
    
 
Job ID:GA-CT- 3765
Job Title:
CARE MANAGER II
Rate:
Primary Skills:
Description:
CARE MANAGER II  - ATLANTA
GROWING health plan membership has created a need for an experienced RN – incredible career potential.
This organization has been recognized nationally for their programs of care.
Will RELOCATE you if needed!!  Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care.
•  Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options
•  Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes
•  Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients
•  Provide patient and provider education
•  Facilitate member access to community based services
•  Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan
•  Actively participate in integrated team care management rounds
•  Identify related risk management quality concerns and report these scenarios to the appropriate resources.
•  Case load will reflect heavier weighting of complex cases than Care Manager I, commensurate with experience
•  Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems
•  Direct care to participating network providers
•  Perform duties independently, demonstrating advanced understanding of complex care management principles.
•  Participate in case management committees and work on special projects related to case management as needed
Qualifications:
-Graduate from an Accredited School of Nursing.
-Bachelor’s degree in Nursing preferred.
-2+ years of clinical nursing experience in a clinical, acute care, or community setting and 1+ years of case management experience in a managed care setting.
-Knowledge of utilization management principles and healthcare managed care.
-Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs.
-Current state’s RN license.
 
    
 
Job ID:GA-CT-3389
Job Title:
Data Analyst III or IV
Rate:
Primary Skills:
Description:
Data Analyst III or IV

Great leadership team- generous benefits & bonus  potential!  Senior level analyst will handle complex data projects for this growing health plan.   You will be a key resource to senior management for driving business decisions based on data. 

Daily activity may include:

-Providing advanced analytical support in any of the following areas:  claims, provider data, member data, clinical data, HEDIS, pharmacy, external reporting.

-Extract, load, model, and reconcile large amounts of data across multiple system platforms and sources

-Review data to determine operational impacts and needed actions; elevate issues, trends, areas for improvement and opportunities to management.

-Develop reports and deliverables and make recommendations to management

-Model data using MS Excel, Access, SQL, and/or other data ware house analytical tools

-Ensure compliance with federal and state deliverable reporting requirements by performing data quality audits and analysis.


Education/Experience: Requested :

-Bachelor’s degree related field or equivalent experience.

-Data Analysis Enterprise Reporting & Analysis Tools-SQL
-6+ years of statistical analysis or data analysis experience or 3+ years of HEDIS data analysis experience including measurement and rates impacted.
- Advanced knowledge of Business Intelligence Tools, SQL, and Microsoft Applications, including Excel and Access.