Medicaid Business Intelligence Lead Jobs

Become a part of our caring community The Business Intelligence Lead serves as the primary analytics and enrollment operations expert supporting Medicaid Enrollment. This role is responsible for leading state implementation readiness efforts, regulatory and contractual reporting support, enrollment analytics, compliance monitoring, and analytics modernization across Medicaid markets. The Business Intelligence Lead solves complex business problems and operational challenges using internal and external data sources to provide actionable insights and strategic direction to business leaders. This role serves as the primary analytics lead supporting Medicaid Enrollment Operations initiatives, with responsibility for state implementation readiness, enrollment analytics, compliance monitoring, and scalable solution architecture. This associate functions as a strategic individual contributor and internal consultant, partnering with business leaders, operational teams, compliance organizations, and technology partners to design and implement analytics solutions. The Business Intelligence Lead exercises independent judgment and decision-making authority on complex issues affecting state compliance, enrollment operations, contractual reporting obligations, membership reporting, reconciliation processes, and operational performance. The role leverages modern analytics platforms including Databricks, Power BI, SQL, and cloud-based data environments to create reusable and scalable solutions supporting current and future Medicaid market expansions. This associate is expected to influence strategy, identify opportunities for operational efficiencies, establish reporting standards, and drive modernization efforts that reduce implementation effort while improving compliance, operational visibility, and business outcomes. Use your skills to make an

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Join a high-performing actuarial team supporting CVS Health and Aetna's exciting and growing Medicaid business. Support CVS Health's financial integrity by leading actuarial forecasting with sound practices to meet the business needs and ensure reasonable actuarial projections. A Brief Overview The primary focus of this director role will be leading actuarial support for the financial forecast modeling of the Medicaid line of business with a secondary focus on trend analysis & development. This role will primarily provide oversight and leadership of activities related to forecasting with a secondary focus on trend normalization and projection. Fundamental Components Primary Role (70% time): Lead budget and forecast storytelling for the Medicaid business. Oversee forecast model development and improvement, and support plan actuaries in understanding forecast projections. Drive forecast related analysis including development of key assumptions, evaluation of financial experience and trend drivers. Review budget and forecast from a business perspective and ensure sound actuarial projections. Identify and support process improvement through automation and process simplification; assure timely and accurate deliverables. Manage high visibility and complex projects. Allocate and align resources. Se

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Aetna Better Health is Aetna’s Medicaid managed care plan. Backed by over 30 years of experience managing the care of those with a broad array of health care needs, our Medicaid plans have demonstrated that getting the right help when you need it is essential to better health. That’s why Aetna® Medicaid plans include the guidance and support needed to connect our members with the right coverage, resources, and care. We are focused on enhancing quality and population health outcomes while integrating CVS assets to bring accessible healthcare to our members. Aetna Better Health of Maryland is seeking an experience leader with vast operational knowledge of Medicaid for its state-wide managed Medicaid business in the role of Chief Operations Officer (COO). The COO role will be strategic and committed to developing colleagues as well as relentlessly pursuing change that is best for the organization and its customers. The COO role will collaborate with the CEO to develop the strategic vision of the Health Plan, policies & procedures, and operational objectives including leading RFP readiness efforts. The COO will oversee high level strategic and operational activities of various plan functional areas which include traditional service operations (Claims, Provider Services, Information Technology, Grievance & Appeals and Member Services) as well as Medical Management (Quality, Netw

Become a part of our caring community The Director, HR Business Partner leads the people agenda for Humana Healthy Horizons by aligning talent strategy with business strategy and converting business priorities into organizational, leadership, workforce, talent, and culture outcomes. The role is accountable for enabling performance across both the run the business and grow the business agendas. This includes ensuring the Medicaid organization has the workforce capacity, leadership depth, organizational capability, and talent strategies required to deliver current commitments, compete for new business, implement awarded business, and scale successfully. The Director serves as a trusted accountability partner to senior leaders, shapes business decisions through workforce and organizational insight, represents the voice of the business across HR, and orchestrates integrated support from HR Centers of Excellence. The role maintains disciplined ownership of assessment, strategy, execution, and measurable outcomes rather than defaulting to advisory or transactional HR delivery. Primary Responsibilities and Accountabilities 1. Business Strategy and Growth Own translation of business strategy into workforce, leadership, talent, culture, and organizational strategies that enable current business performance and future growth. Assess business priorities, growth opportunities, operating challenges, and organizational risks to determine the people and organizational actions required to achieve business objectives. Establish and execute integrated plans that support market performance, business expansion, procurement activity, awarded business, implementation, and long-term scalability. Ensure workforce and organizational implications are identified, tested, and addressed as strategic choices and growth opportunities

Become a part of our caring community The Senior HR Business Partner will lead the people management agenda aligned to Medicaid RFP/RFI/RFA responses. Their work will align to standing up markets and supporting current markets in collaboration with the aligned HR Business Partner Lead (HRBPL) and act as a facilitator for the company's management team. They will need to apply broad experience in various Humana Resources (HR) areas of expertise. Work assignments will involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Senior HR Business Partner acts as a single point of contact for a broad range of business and HR partners across the Retail segment. Work will focus cyclically on the support of Medicaid RFA/RFI/RFP responses and the subsequent stand up or change of markets and work across partners in Medicaid, HR and other shared services to ensure the successful bid and stand up/operation of new and existing plans. In addition this work is closely aligned with the work of HRPBLs on this team and others to lead a strategy that ensures the successful growth and operation of our Medicaid line of business and facilitate superior member care delivery in all states. Responsibilities will include the identification, documentation, and implementation of best practices and support of the delivery of HR processes across Medicaid. This role will be accountable for identifying gaps, proposing and implementing changes necessary to cover risks and will act as a performance improvement driver and provoke positive changes in people management, lead change management projects and facilitate HR related internal and external communication. The successful candidate will influence our department’s strategy, make decisions on moderately complex to complex issues regarding technical approach for project com

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Risk Management is charged with protecting company assets. This group is responsible for minimizing risk – in legal, financial and operational areas – and its affects on the organization, as well as for enforcing security and safety measures. Coordinate effective resolution of member and/or provider/practitioner appeals, complaints and grievances. Responsible for the day-to-day management of staff to ensure effective resolution of member or provider/practitioner appeals, complaints and grievances for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Responsible for day-to-day implementation of Aetna's appeals, complaints and grievances policies and procedures. Identifies trends and issues; reports on and recommends solutions. Accountable for meeting the financial, operational, and quality objectives of the unit. -Manages team's productivity and resources, communicates productivity expectations and balances workload to achieve customer satisfaction through prompt/accurate handling of customer concerns. -Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation req

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary At Aetna®, part of CVS Health, we proudly serve more than 26 million medical members through our broad range of health plan offerings. We're committed to delivering a simpler, more meaningful, and personal health care experience to each of them. As a Medicaid Proposal Writer, you will play a critical role in the quality of our RFP responses and the efficiency of the whole team. As the Proposal Writer, you will continuously strive to increase your knowledge of Aetna Medicaid, products offered, and industry best practices to develop thoughtful, strategic, compliant responses to RFPs/RFIs. This role is a work from home opportunity, which can be based anywhere in the United States. Job Responsibilities: Work on writing assignments varying in length and detail supporting strategic, functional, and operational topics across the entire proposal Collaborate with Capture and Proposal Managers, Proposal Directors, and Subject Matter Experts to outline and prepare final proposal responses Analyze proposal sections and content development to identify connections, ensure alignment, and support a cohesive overall narrative Interviews with subject matter experts (SMEs) to identify and collect pertinent information for compliant and compelling responses, upd

Job Title Sales, Territory Manager - RespirTech (Houston) Job Description RespirTech’s Territory Manager represents the InCourage airway clearance therapy medical device, calling on but not limited to Pulmonologists to support patients with chronic respiratory and neuromuscular conditions on a journey to better breathing. Your role: Executing outside sales and territory management, inclusive of account management and new business development. Employing a hunter mentality to identify new opportunities, overcome objections and change the mindsets of prescribers, while achieving performance growth goals. Performing total office sales calls, in-services on patient profiles, product demonstrations and presenting clinical evidence to physicians. Being an expert on Medicare, Medicaid and private insurance coverage-criteria for InCourage vest therapy, while effectively educating healthcare teams in identifying patients who meet coverage criteria. Obtaining medical record documentation in order for coverage to be obtained. Analyzing data to effectively target priority healthcare teams and create sales call routing. Capable to be flexible and adjust routing to fit pipeline management needs. You're the right fit if: You’ve acquired 3+ years of successful direct field sales, clinical education or clinical sales support experience. Previous durable/home medical equipment and/or pharmaceutical sales experience preferred. Your skills include: Ability to be in the field within your territory 90% (some territories may include overnights). The ability to build and maintain strong customer relationships. You have a Bachelor’s Degree in Business Administration, Marketing, Sales or equivalent (preferred) or 7+ years of field sales experience. You must be able to successfu

Job Title Sales, Territory Manager (Allentown/Scranton, PA) Job Description RespirTech’s Territory Manager represents the InCourage airway clearance therapy medical device, calling on but not limited to Pulmonologists to support patients with chronic respiratory and neuromuscular conditions on a journey to better breathing. Your role: Executing outside sales and territory management, inclusive of account management and new business development. Employing a hunter mentality to identify new opportunities, overcome objections and change the mindsets of prescribers, while achieving performance growth goals. Performing total office sales calls, in-services on patient profiles, product demonstrations and presenting clinical evidence to physicians. Being an expert on Medicare, Medicaid and private insurance coverage-criteria for InCourage vest therapy, while effectively educating healthcare teams in identifying patients who meet coverage criteria. Obtaining medical record documentation in order for coverage to be obtained. Analyzing data to effectively target priority healthcare teams and create sales call routing. Capable to be flexible and adjust routing to fit pipeline management needs. You're the right fit if: You’ve acquired 3+ years of successful direct field sales, clinical education or clinical sales support experience. Previous durable/home medical equipment and/or pharmaceutical sales experience preferred. Your skills include: Ability to be in the field within your territory 90% (some territories may include overnights). The ability to build and maintain strong customer relationships. You have a Bachelor’s Degree in Business Administration, Marketi

Become a part of our caring community The HR Business Partner 2 leads the people management agenda in a business unit/area, and acts as a facilitator for the company's management team. Applies broad experience in various Humana Resources (HR) areas of expertise. The HR Business Partner 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The HR Business Partner 2 acts as a single point of contact for the employees and managers in the business unit/area in the Medicaid RFP Response and Implementation team and their people management agenda. Possesses a deep knowledge of the business unit / area, key employees and business processes. Builds a strong business relationship with the business unit/area and transfers HR requests and solutions to/from the business unit. Implements best practices and supports the delivery of HR processes at the business unit/area. Identifies gaps, proposes and implement changes necessary to cover risks. Acts as the performance improvement driver and provokes positive changes in the people management. Leads the change management projects and manages the HR related internal and external communication. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. This position will focus primarily on the HR related activities tied to a response for RFPs and the subsequent stand up of new business. The position will work across the HR organization to build, run and analyze data in support of RFPs and stand up of new business and ensure the alignment and timing of resources key to the operational stand up of

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary: This is an individual contributor role. As part of the bold vision to deliver the “Next Generation” of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among MCOs, vendors, and ODM to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems. This position assesses overall network composition and potential provider partners in order to identify and service partnerships that will advance and differentiate the OhioRISE Network. This executes, services and may negotiate contracts with local market providers in accordance with company and program standards to enhance provider networks and exceed accessibility, quality, and financial goals and cost initiatives. Key Responsibilities: Optimizes interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships and partners in the development of business strategy and programs to support the operational plans. Collaborates cross-functionally to ensure resolution of escalated issues or

Become a part of our caring community The Senior Quality Improvement Professional leads efforts to improve clinical quality and provider performance for the Humana Healthy Horizons in South Carolina Medicaid Plan. You will develop and implement cross-functional quality improvement initiatives, evaluate business processes and performance outcomes, and drive sustainable, measurable improvements. Reporting to the Quality Improvement Director, you will collaborate with internal and external stakeholders to advance a provider-focused culture of quality and performance excellence. You will manage complex projects and analyze diverse data sources to identify opportunities, inform strategy, and support organizational objectives. The Senior Quality Improvement Professional leverages data to lead quality improvement initiatives, monitor performance metrics, and support provider performance enhancement. This role collaborates with provider-facing teams to implement targeted interventions, develop educational resources, and drive achievement of quality and member experience goals. The position leads and participates in multidisciplinary committees, provides strategic clinical guidance on quality initiatives, and influences business decisions through data-driven insights. Operating with a high degree of independence, the Senior Quality Improvement Professional manages complex projects, exercises sound judgment, and recommends solutions to advance organizational objectives. Essential Role Responsibilities The Senior Quality Improvement Professional is responsible for improving clinical quality and performance outcomes among South Carolina network providers. Key responsibilities include: Partner with Provider Engagement, Network, and Contracting teams to implement clinical quality improvement strategies including education, training and performanc

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary This person is responsible for making outbound calls to prospective members, specifically offering our Medicare plan. The Account Associate will be making outbound calls for retention efforts, as well as providing support to sales representatives as needed. Additionally, this person will respond to incoming customer service inquiries as needed. The Account Associate should be available to work alternate hours (such as overtime or weekends) as needed, depending on business needs. Required Qualifications Must reside in Maricopa County, AZ. 1&#43; year of experience in a call center environment, with demonstrated telephone and problem resolution skills. 1&#43; year of experience with Medicaid and/or Medicare. Demonstrated proficiency in basic computer software, primarily Microsoft Office. Preferred Qualifications Bilingual (English/Spanish). Previous experience working with Quick Base. Strong organizational and time management skills. Excellent attention to detail. Self-starter, with an ability to succeed in an independent environment. Education High school diploma or GED. Anticipated Weekly Hours 40<p s

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The growing DSNP business has created an opportunity for an individual with claims experience, who is familiar with the 837 standard claims format. This individual will own 837 file transmissions to the states, manage and act on state response files, ensuring that all transactions transmitted are complete and error free. Manage and complete error corrections to meet state requirements. Required Qualifications 1&#43; year of experience with encounter data, medical claims, or Medicare/Medicaid. 1&#43; year of experience using FTP and data transfer software. 1&#43; year of data management experience. Preferred Qualifications Experience with Microsoft Access Databases. Analytical skills with the ability to identify and resolve data discrepancies. Working knowledge of the 837 claims files. Education Bachelors degree or equivalent work experience Anticipated Weekly Hours 40 Time Type Full time Pay Range <p s

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary We are seeking an experienced actuarial professional to support Medicaid managed care pricing evaluation, financial performance management, and strategic decision-making. This role requires a strong combination of actuarial expertise, business acumen, technical proficiency, and leadership capability. The successful candidate will serve as a key partner to market leadership, finance, and operational stakeholders while providing guidance and oversight to actuarial analysts supporting complex Medicaid markets. This position is ideal for an actuary with strong project management skills who can balance short-term deliverables and ad hoc requests with long-term strategic initiatives, thrive in a dynamic environment, and independently develop analyses to address emerging business questions. Medicaid Pricing and Actuarial Analysis • Lead actuarial evaluation of state capitation pricing and forecasting for Medicaid managed care programs. • Evaluate and interpret complex state rate-setting methodologies, risk adjustment programs, acuity adjustments, and regulatory requirements. • Assess revenue, medical cost, utilization, and margin drivers to identify emerging trends and business risks. • Summarize and communicate actuarial analysis for business leadership. Strategic Business Support • Partner with market, product, finance, and operations tea