2 Care Management Jobs

Role & responsibilities Come join our team! Help us tackle the data usability challenge for payers. Your expertise and experience will help drive meaningful performance outcomes. You'll also have the chance to advance your career, acquire new skills, and collaborate with some of the most innovative minds in payer data management. We are seeking an experienced Business Analyst with Utilization Management and Care Management subject matter expertise to join our growing team. You will act as a liaison between business stakeholders, the data modeling team, and technical teams, ensuring client needs and business requirements are translated into actionable technical specifications resulting in seamless data exchange and efficient data integration between formats and systems. You will contribute expertise and experience in both analytic and operational components of utilization management and care management. Within utilization management, your experience in payer-focused utilization review processes in clinical and/or pharmacy context, including prior authorization, concurrent review, appeals/denials, regulatory compliance, and with data analysis will help shape the product. Within care management, deep understanding of care management operations and plans, program evaluation, data analysis and interpretation (claims, authorizations, case management,, and member engagement will also help shape the product. Finally, demonstrated expertise in data mapping and transformation and technical requirements gathering and analysis will help optimize client implementations and develop client-facing solutions that drive business value for payers in critical programs surrounding utilization and care management, including the interplay between this area and Value Based Care, Population Health, CMS Interoperability, and Quality. You Will Be Responsible for: Requirements Gathering and Analysis . Define, analyze, and document detailed functional and technical requirements for specific data solutions. Tasks may include collecting requirements from internal SMEs, partnering closely with Client Delivery and/or Customers to gather and refine technical and business requirements, developing and reviewing QA/user acceptance testing criteria, and business systems analysis, including data and gap analyses. Stakeholder coordination/collaboration : Be a knowledgeable bridge between clients, product management, data modeling, SMEs, and other team members to define, document and share detailed functional and technical requirements and expected impact using all of the tool in your technical BA toolkit. Mock-ups/Prototyping : Create mocks-ups, sample reports, and/or output tables to help visualize and communicate requirements, workflows, and expected results, based on client problems to be solved, business rules, and technical requirements. User Acceptance Testing/QA Process . Collaborate with key stakeholders to define user stories, test cases, QA/User acceptance testing criteria for data solutions. Partnering with Agile Scrum Teams : Participate in relevant agile ceremonies, build user stories according to requirements, and help define test cases and acceptance criteria. Solution Maintenance . Co-own maintenance and create of artifacts that includes but is not limited to document portal/repository, workflows/diagrams, data mapping and technical requirements documents, analytics/business logic, user stories, and UAT scenarios and test cases. Continual Learning . Keep up to date on latest industry trends in how payers are using data to drive improvement in outcomes. Leverage this expertise to continue to refine how solutions are developed and refined to maximize value for clients. Must-Have Qualifications: Deep understanding of how US Health Insurers (payers) utilization management and care management programs clinical and pharmacy, including prior authorization processes, workflows, regulatory compliance, data analysis and interpretation (claims, authorizations, case management), and member engagement 5+ years of experience working with US healthcare data (claims, clinical, member, provider, CMS files, etc.) and standards (e.g., HL7, FHIR, EDI, CDA) and integration 5+ years of progressive experience in business requirements management (definition, documentation, mock-ups, data analysis) 3+ years experience participating in UAT process management – test case planning and scenarios, writing UAT acceptance criteria, UAT test case execution, tracking and resolving defects, and UAT closure Proficiency in data mapping and data exchange protocols (e.g., API, JSON, XML) related to health information systems. Proficiency in SQL, Python, and/or other programming languages for data extraction and transformation. Working knowledge of UM and Care Management systems of record Strong communicator who can share domain expertise effectively across multiple departments from Sales, Client Delivery, Product, Engineering, and Information Security "Roll up your sleeves mentality" working side-by-side with your team. Self-starter with demonstrated ability to drive workstreams independently and manage risks with strong compass on when to escalate issues. Demonstrated ability to thrive in a fast-paced, dynamic startup environment. Nice-to-Have Qualifications: Working knowledge of US healthcare (one or more) - health insurance markets, government sponsored health plans (Medicare/Medicaid), and/or care delivery and reimbursement models (e.g. VBC, population health, risk adjustment) Familiarity with cloud platforms (e.g., AWS, Azure, Databricks, Snowflake, etc.) for hosting healthcare applications and data storage. Experience with EHRs and/or HIEs and healthcare data workflows. Experience with healthcare analytics and data visualization tools (e.g., Power BI, Tableau) Experience with Agile methodologies in healthcare technology projects. Interest in Advanced Analytics, Data Science, and/or GenAi Preferred candidate profile

Job Description: Solicit, review and analyze business requirements Write business and technical requirements Communicate and validate requirements with stakeholders Validate solution meets business needs Work with application users to develop test scripts and facilitate testing to validate application functionality and configuration Participate in organizational projects and/or manage small/medium projects related to assigned applications Translates customer needs into quality system solutions and ensures effective operational outcomes Focus on business value proposition*Apply understanding of 'As Is' and 'To Be' processes to develop solution Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). Role Focus Areas: Core Expertise Required: Provider Management Utilization Management Care Management Domain Knowledge: Value-Based Care Clinical & Care Management Familiarity with Medical Terminology Experience with EMR (Electronic Medical Records) and Claims Processing Technical/Clinical Understanding: Admission & Discharge Processes CPT Codes, Procedure Codes, Diagnosis Codes Job Qualification: Undergraduate degree or equivalent experience. Minimum 5 Years experience in Business Analysis in healthcare including providing overall support, maintenance, configuration, troubleshooting, system upgrades, and more for Healthcare Applications. Good experience on EMR / RCM systems Demonstrated success in running EMR / RCM / UM, CM and DM systems support in requirements, UAT, deployment supports Experience working with stakeholders, gathering requirements, and taking action based on their business needs Proven ability to work independently without direct supervision Proven ability to effectively manage time and competing priorities Proven ability to work with cross-functional teams Core AI Understanding AI/ML Fundamentals: Understanding of supervised, unsupervised, and reinforcement learning. Model Lifecycle Awareness: Familiarity with model training, evaluation, deployment, and monitoring. Data Literacy: Ability to interpret data, understand data quality issues, and collaborate with data scientists. AI Product Strategy AI Use Case Identification: Ability to identify and validate AI opportunities aligned with business goals. Feasibility Assessment: Understanding of whats technically possible with current AI capabilities. AI/ML Roadmapping: Planning features and releases that depend on model development cycles. Collaboration with Technical Teams Cross-functional Communication: Ability to translate business needs into technical requirements and vice versa. Experimentation & A/B Testing: Understanding of how to run and interpret experiments involving AI models. MLOps Awareness: Familiarity with CI/CD for ML, model versioning, and monitoring tools. AI Tools & Platforms Prompt Engineering (for LLMs): Crafting effective prompts for tools like ChatGPT, Copilot, or Claude. Responsible AI & Ethics Bias & Fairness: Understanding of how bias can enter models and how to mitigate it. Explainability: Familiarity with tools like SHAP, LIME, or model cards. Regulatory Awareness: Knowledge of AI-related compliance (e.g., HIPPA, AI Act). AI-Enhanced Product Management AI in SDLC: Using AI tools for user story generation, backlog grooming, and documentation. AI for User Insights: Leveraging NLP for sentiment analysis, user feedback clustering, etc. AI-Driven Personalization: Understanding recommendation systems, dynamic content delivery, etc.