Amerihealth Caritas

Oversee daily operations, staff management, and compliance for appeals and grievances in a healthcare setting. | Requires 3+ years leading clinical/non-clinical staff, healthcare operations experience, and knowledge of healthcare regulations, which your experience does not include. | Job Summary As the Supervisor, Appeals and Grievances you will oversee daily operations, staffing, and performance for a remote team of 15 Appeals & Grievance Specialists, Administrator, and Team Leads supporting our Pennsylvania Medicaid business. This role ensures that all provider appeals and grievance cases are processed accurately, timely, and in full compliance with applicable federal, state, and accreditation standards (CMS, NCQA, URAC, and state regulations). In addition, you will ensure collaboration between team members and leadership, coordinate workflow, maintain quality standards, monitor compliance metrics, and promote a culture of accountability and professional growth. Work Arrangement • Remote- must be near Philadelphia for meetings • Monday through Friday from 8a EST to 5p EST Responsibilities • Leadership and Staff Management • Supervise daily activities of assigned Appeals & Grievance staff, including scheduling, workload distribution and case prioritization • Provide ongoing coaching, performance feedback, and mentoring to develop Associate competencies • Serve as the first line of escalation for complex cases, providing subject matter expertise and decision support • Operational Oversight • Monitor daily inventory levels, turnaround times, and productivity metrics to ensure operational goals are met • Review and approve case documentation and correspondence for completeness, accuracy, and compliance • Ensure all appeals and grievance activities adhere to departmental policies, and standard operating procedures (SOPs), and regulatory requirements • Assist in the development and revision of procedures and workflow documentation to improve efficiency and accuracy • Compliance & Quality • Maintain departmental compliance with all regulatory requirements (CMS, NCQA, URAC, and state specific regulations) • Conduct routine case audits and quality reviews; document findings and implement corrective actions • Partner with Compliance and Quality departments to prepare for internal and external audits • Reporting & Communication • Track and report on key operational metrics, including productivity, accuracy, and compliance indicators • Cross-Functional Collaboration • Coordinate with Claims, Utilization Management, Member Services, Legal, and Compliance to ensure Consistent resolution of appeals and grievances Education and Experience • Associate Degree in Health Administration, Business, or related field. • Preferred Experience Level (if different from minimum required): Knowledge of medical terminology, benefit interpretation, and regulatory processes preferred. Prior experience working with CMS, Medicaid, or state-regulated appeals processes preferred. • Minimum of 3 years of experience leading a team of clinical and non clinical staff • Minimum of 5 years experience in healthcare operations, managed care, compliance, or grievance/appeals coordination • Demonstrated experience overseeing complex or escalated cases within a managed care organization. Skills and Abilities • Proven leadership and people management skills • Proficiency in Microsoft Office Suite (Word, Excel, Outlook, etc.) • Demonstrated knowledge of CMS, NCQA, and state-specific appeals and grievance requirements • Strong analytical, investigative, and documentation abilities • Excellent written and verbal communication • Ability to manage multiple priorities with accuracy in a fast-pace environment • Customer service mindset and professional demeanor Your career starts now. We’re looking for the next generation of health care leaders. At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com. Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

Lead cross-functional strategic initiatives, analyze operational data, and develop executive dashboards and reports. | Requires 5-10 years in process improvement, healthcare operations, and project management, with strong analytical, communication, and organizational skills. | Role Overview: The Market Executive Projects Manager (PM) plays a critical role in driving strategic initiatives that enhance operational efficiency, strengthen regulatory compliance, and support overall organizational performance. This role leads cross‑functional projects, evaluates and improves processes, and delivers actionable insights through data analysis, reporting, and executive‑level presentations. The PM partners closely with leadership and key internal and external stakeholders to ensure operational alignment with organizational goals and state requirements. Additionally, overseeing information flow across teams, developing dashboards and performance metrics, supporting special projects, and contributing to strategies that enhance readiness, mitigate risk, and foster organizational growth. Work Arrangement: • Hybrid - Associate must be in the office at least two (2) days per week at our Southfield, Michigan (MI) location, including core days of Tuesdays and Wednesdays. Responsibilities: • Identify, design, and implement strategic initiatives that support the organization’s business goals and regulatory requirements. • Conduct operational assessments, analyze data, and recommend process improvements and cost‑efficiency solutions. • Facilitate workgroups and cross‑functional teams to support collaboration, decision‑making, and project success. • Develop dashboards, performance metrics, and reporting tools to inform executive leadership and governance committees, enabling them to make informed decisions. • Prepare clear, concise presentations and executive summaries for internal and external audiences, including leadership and Boards. • Monitor progress toward organizational goals and document updated workflows, improvements, and performance trends to ensure ongoing effectiveness and efficiency. • Support contractual obligations, risk mitigation, and operational readiness. • Translate complex analytical findings into actionable business recommendations. • Ensure adherence to regulatory and contractual requirements across assigned projects. Education & Experience: • Bachelor’s degree required; master’s degree preferred • 5 to 10 years of relevant experience in process improvement, healthcare operations, and project management Skills & Abilities: • Strong analytical and critical‑thinking skills • Ability to lead and influence without formal authority • Excellent written and verbal communication • Strong organization and prioritization abilities • Proficiency in developing presentations, dashboards, and executive‑ready deliverables • Ability to manage multiple complex projects simultaneously • Knowledge of managed care operations, plan benefits, and regulatory standards • Experience interpreting data and implementing risk mitigation strategies • Proficient in MS Office & Projects

Lead and mentor business analyst teams on appeals system projects, manage requirements and change processes, provide SME expertise on appeals and audits, and drive process improvements. | Bachelor's degree or 5+ years appeals experience, leadership of BA resources, proficiency in Tableau and SQL, strong communication and facilitation skills, and appeals system SME knowledge. | Must live within a commutable distance to Newtown Square, PA Your career starts now. We are looking for the next generation of health care leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com. The Business Analyst Sr -Corporate Appeals applies advanced subject matter knowledge to complex business issues and is regarded as a subject matter expert on all lines of business for appeals. Frequently contributes to the development of new ideas and methods. Works on complex problems/projects where analysis of situations or data requires an in-depth evaluation of multiple factors. Exercises significant independent judgment within broadly defined policies and practices to determine best method for accomplishing work and achieving objectives. Leads and provides expertise to functional projects, audits, reports, and may participate in cross-functional initiatives. Responsibilities Include: • Provide mentoring and guidance to lower level associates. • Acts as expert providing direction and guidance to process improvements and establishing policies. Can represent the organization to external clients. • Serves as a liaison between client, technical and other project groups using superior communication skills to elicit, document, analyze and validate requirements. • Works on the appeal system upgrades as SME • Is an Appeals Audit SME, assisting all teams with audit prep and audit presentation • Applies industry-specific expertise to recommend and coordinate the development, enhancement, and maintenance of a client's business systems, processes, and products using high-maturity methods, processes, and tools. Combine industry expertise with a thorough understanding of information technology and processes to develop innovative business solutions. • Influences the strategic direction of clients. Lead analysis teams on large projects. Lead requirements management and change management processes, especially related to appeals system changes, tracking, communication and audits. • Lead business studies and present study results to team, senior management. • Leverage industry knowledge and client relationships to assess the business implications of project impact to current and future business environment to identify new business opportunities. • Promote and direct process improvement activities and training of peers and clients. Education/Experience: • Bachelor's Degree preferred or minimum of 5 years Appeals experience. • Technical or business discipline - Tableau/SQLs • Leadership of Business Analyst resources assigned to projects • Provides time/ resource estimates for assigned projects • May develop innovative solutions to complex business and technology problems. • Leads analysis team of 3 to define requirements and design innovative solutions to complex business and technology problems • Facilitates meetings to ensure business requirements are being met. Other Skills: Requirements include elicitation via interviewing and workshop facilitation; determination using structured techniques for documentation, analysis, evaluation/validation; decom position of high-level information into details; distinguishing requests vs needs; distinguishing requirements vs solutions; classifying/ prioritizing requirements; ensures consistent understanding across users, designers and testers; business process modeling of current state and desired/future state processes; defining and managing scope and client expectations, requirements change management and traceability; identifying and mitigating risks; applying creativity/ innovation to solving complex problems; building relationships and working collaboratively; developing an communicating a vision for project/ system; providing thought leadership; mentoring; effective verbal/written communications; preparing and delivering effective presentations; experience in one or more industry domains. Specialized: Appeals Subject Matter Expert (SME) across all jobs, audit Subject Matter Expertise appeals system. Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.