Medicaid Business Intelligence Lead Jobs

Become a part of our caring community Humana is a publicly traded, Fortune 60 health benefits company with a long history of successful innovation and reinvention. It has transformed itself from the largest US nursing home company in the ’60s, to the largest US hospital corporation in the ’80s, to a leading health benefits company beginning in the ’90s. Today, Humana is a leader in consumer-focused health solutions and is one of the largest health benefits organizations in the country. The Enterprise Growth Strategy team is a newly created organization supporting growth across Humana’s businesses. The team has a strong dotted-line partnership with the Medicare and Medicaid organization, Humana’s largest, which comprises over 80% of the company’s total revenue and the majority of its earnings. Team members partner with the senior leaders of the business unit, and more broadly with leaders throughout the enterprise, as they deliver strategy projects addressing some of the businesses’ most important opportunities and challenges. These high-profile strategy projects place the team at the forefront of helping to define the future of Humana’s largest businesses. Humana is seeking an experienced team member to support delivering some of Medicare and Medicaid’s highest priority projects and initiatives, with an emphasis on Medicare Advantage strategy development. As a Manager, you will deconstruct issues and challenges, perform targeted research and analysis, and craft sound, logical solutions and recommendations. You will also shape implementation considerations, and work with business owners as appropriate to transition analysis into execution. While doing so, you will have the opportunity to collaborate with fellow team members, subject matter experts, members of Humana’s executive Management Team, and corporate, functional, and business unit leaders. </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. ***The ideal candidate will reside in larger New York area*** Position Summary The Senior Manager, Financial Planning and Analysis role will function as the Financial Planning and Analysis lead the New York Medicaid Health Plan and will support the CFO directly to achieve financial and strategic goals by managing and driving business actions and financial goals across the Plan. This position will oversee the development, analysis, and reporting of financial forecasts, budgets, and key performance metrics to support strategic decision-making. This role ensures alignment of financial strategies with state Medicaid requirements and corporate goals, providing actionable insights to executive leadership and cross-functional teams. With significant budget oversight and authority, the position drives financial performance, manages operational complexities, and assesses opportunities to enhance profitability and efficiency in a dynamic healthcare environment. Key interactions include executive leaders, operational managers, and state Medicaid stakeholders. The Senior Manager will: Oversee the development of comprehensive financial reports that align with strategic goals. Leads the identification of key financial variances and trends, providing insights for strategic decisions. Lea

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. Job Purpose and Summary: Accountable for Commercial, Medicare, Exchange and Medicaid NCQA Accreditation quality projects and initiatives through design, development, and implementation. This role focuses primarily on Delegated Credentialling and Oversight of the delegated Credentialling organizations, per contract. Proactively builds strong business relationships with internal and external business partners. Participates in presentation to business partners on accreditation requirements to achieve results and ensure accreditation readiness. Proven experience as a subject matter expert on NCQA accreditation standards, analysis, Delegated Credentialing file reviews and supporting quality functions. Primary Job Duties & Responsibilities: Utilizes statistical analysis, data visualization tools, and database queries to identify trends, patterns, and opportunities for quality improvement. Develops and maintains performance metrics and dashboards to track and report on patient safety, clinical effectiveness, patient experience, and compliance with quality standards. Contributes to quality improvement projects and initiatives by providing data-driven insights and recommendations. Collaborates with cross-functional teams to design and implement evidence-based practices, care protocols, and process improvements. Assists in conducting audits and performing chart review

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 Supervisor of Service Operations will maintain oversight of a team of claim processors and all claim related functions for Medicaid Claim Operations. We are seeking a highly motivated individual who will establish a clear vision aligned with company values and team goals. The claim Supervisor works with staff to align daily processing activities to successfully meet Health Plan metrics. Responsibilities will include: Managing a team of claim processors and overseeing daily operations for assigned health plan to achieve state required metrics. Manage employee performance and development. Identifies risks and barriers and collaborates with business partners to improve processes. Coaches and mentors team members, assisting with complex questions and customer interactions. Acts as liaison between staff and other areas, communicating workflow results, ideas, and solutions. Completes various business reports, including tracking, trending and results. Works with the Medicaid leadership team to allocate resources to meet volume and performance standards. Builds a cohesive team through collaboration, inclusion, and diverse thinking. Ability to work in a fast-paced production environment. Required Qualific

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 Location: Work From Home – Flexible, Travel Required: 25 – 50% (Wayne and Macomb Counties) Schedule: Standard business hours Monday-Friday 8:00am-5:00pm EST No evenings, weekends, or major holidays 4 day/10-hour schedule available after training ​ Our Mission The LTSS RN Case Manager is responsible for comprehensive assessment, care planning, coordination, implementation, and monitoring of Long-Term Services and Supports (LTSS) for dual-eligible Medicare and Medicaid members. This role ensures members receive appropriate waiver and community-based services to promote safety, independence, and improved health outcomes while maintaining regulatory compliance. This position includes in-home visits to complete functional assessments, evaluate eligibility for waiver services, and develop person-centered service plans. Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our members who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and

Become a part of our caring community Humana, a Fortune 60 Healthcare Company Humana is a publicly traded, Fortune 60 health benefits company with a long history of successful innovation and reinvention. It has transformed itself from the largest US nursing home company in the ’60s, to the largest US hospital corporation in the ’80s, to a leading health benefits company beginning in the ’90s. Today, Humana is a leader in consumer-focused health solutions and is one of the largest health benefits organizations in the country. The Consumer Product s Enablement & Solutions department supports Humana’s businesses by ensuring co nsumer products are competitive and meet consumer needs. The team also enables growth across the organization and ensures timely CMS and state filing timelines. The team has a strong dotted-line partnership with the Medicare and Medicaid organization, Humana’s largest , which comprises over 80% of the company’s total revenue and the majority of its earnings . Team members partner broadly with leaders throughout the enterprise, as they provide oversight and strategic direction of all Medicare and Duals products. Humana is seeking an experienced team member to help drive strategic direction and ensure execution on the end-to-end proces ses and projects critical for transformation across our business . As a Consultant , you will <

Louisiana Medicaid Inbound Contact Representative — Louisiana. Apply via Workday.

Indiana Medicaid Inbound Contact Representative — Indiana. Apply via Workday.

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: Ready to take your Medical Director career to the next level with a Fortune 6 company? Join Aetna, a CVS Health company, and make a meaningful impact on the health and well-being of Medicaid members across the country. Aetna operates Medicaid managed care plans in Arizona, Florida, Illinois, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Texas, Virginia, and West Virginia. We are seeking a Medical Director to join our centralized Medical Management team. This work-from-home position will primarily support Aetna Better Health of Louisiana , while also providing support across the other health plans as needed. In this role, you will partner with Medical Management staff to ensure timely, consistent, and clinically sound decisions for members and providers. Key responsibilities include: Utilization Management and medical necessity reviews Prior authorization and precertification determinations Concurrent review for inpatient and outpatient services Acute and post-acute care reviews Peer-to-peer consultations with treating providers Pharmacy reviews and first-level appeal determinations Collaboration with multidisciplinary clinical and operational teams The Medical Director also participates in a rotating on-c

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 Ready to take your clinical skills to the next level? Check out this outstanding opportunity for a Medicaid Prior Authorization Pharmacist with Aetna! This is a Clinical Pharmacist position supporting Medicaid Prior Authorization. An active TX or AZ pharmacist license that is in good standing is required. New hire is required to obtain the secondary license (AZ or TX) within 90 days of hire . We are hiring for the 10:30 am - 7:00 pm CST shift (post training). The training schedule is: 10:00 am - 6:30 pm CST. You will be required to work one Saturday every 4-6 weeks and occasional holidays. This is a fully remote position open to qualified candidates within the United States who currently hold active, unrestricted TX or AZ pharmacist licensure. Required Qualifications - Active and unrestricted TX and/or AZ pharmacist license - New hire is required to obtain the secondary license (AZ or TX) within 90 days of hire . - Demonstrated experience with clinical decision-making while applying evidence-based clinical guidelines/criteria; utilizing formularies/preferred drug lists. - Experience working in a high production, remote team environment - 3&#43; years experience working as a pharmacist or completion of PGY1 managed care residency, includin

Become a part of our caring community Humana Healthy Horizons is looking for a Value-Based Programs Lead who will support successful value-based provider relationships with a focus on improving the provider experience and achieving path-to-value goals. You will lead the beginning-to-end operational support of specialty Medicaid value-based payment (VBP) models in alignment with segment strategy and goals. The Value-Based Programs Lead will be a subject matter expert in VBP and have advanced technical knowledge and experience. Develop new innovative VBP models for range of provider types, such as behavioral health, maternity, specialists, and social determinants of health, creating glide paths to move providers from volume to value. Align scope of work with roadmap for new VBP model development to ensure compliance with Medicaid contractual requirements and RFP commitments. Analyze financial, utilization, and performance data to identify opportunities to drive improvements in quality and/or reductions in total cost of care. Creation of VBP payment strategies and model design, such as developing payment model logic, performance metrics and benchmarks, and financial terms, which align with segment goals. Design and contribute to development of provider reporting packages to help providers understand their overall and detailed performance. Partner with finance team to conduct impact analysis and modeling for new VBP models. Collaborate with team members and matrixed teams to operationalize and rollout of new VBP models. Contribute to developing solutions to operational gaps. Monitor VBP model performance KPIs to identify opportunities to enhance model design based on internal and external feedback and performance data. Ability to translate strategy into models that can be piloted and scaled across markets. <

Senior Manager – Aetna Medicaid Controllership COE — RI - Cumberland. Apply via Workday.

Medical Director - Medicaid Appeals — 26 Locations. Apply via Workday.

Proposal Quality Analyst (Medicaid) — Work At Home-Ohio. Apply via Workday.

Strategic Project Manager - Medicaid Capture Management — Remote Nationwide. Apply via Workday.