Amerihealth Caritas

Manage and support healthcare provider networks, ensuring compliance, performance, and satisfaction. | High school diploma or equivalent, 1-3 years in provider services, 3-5 years in managed care/health insurance, and bilingual in Spanish preferred. | Role Overview: We’re seeking a detail-oriented and relationship-driven Account Executive I to manage and support our network of contracted healthcare providers. In this role, you’ll build and maintain strong partnerships, conduct provider orientations, resolve issues, and ensure compliance with state and federal access requirements. You’ll monitor provider performance using data and metrics, support credentialing processes, and help drive improvements in service delivery. Work Arrangement: • Remote - This role requires residence in Central Florida and 35% travel throughout the assigned territories.; Responsibilities: • Serve as the primary liaison between the Plan and assigned providers, ensuring a deep understanding of contract terms, provider needs, and performance expectations. • Conducted tailored provider onboarding and educational sessions, and issued resolutions to support provider engagement and satisfaction. • Monitor network adequacy and ensure compliance with state and federal access standards across all product lines. • Identify and recruit qualified providers in new and existing service areas, ensuring alignment with financial and contractual requirements. • Analyze provider performance using Plan reports and metrics; develop and implement improvement strategies based on data insights. • Support corrective action processes, including provider terminations, by Plan policies. • Collaborate with the Quality Management team on credentialing, re-credentialing, member complaints, and quality of care investigations. • Maintain accurate provider data in Facets and coordinate updates with the Provider Maintenance Department. • Prepare and submit timely reports on activities, metrics, and outcomes. • Build and sustain effective partnerships with internal departments and stakeholders. Education & Experience: • A bachelor's degree or equivalent experience is preferred. • A high school diploma/GED is required. • 1 to 3 years of experience in a Provider Services position working with providers. • 3 to 5 years of experience in the managed care/health insurance industry. • Medicare, Medicaid, Commercial, or ACA Exchange experience preferred. • Experience in provider data management, including maintaining accurate provider records and databases • Bilingual in Spanish to support diverse provider populations Skills & Abilities: • Establish and maintain trust-based partnerships with healthcare providers and internal teams. • Manage and de-escalate provider concerns or issues with professionalism and diplomacy. • Take initiative, manage time effectively, and complete tasks with minimal supervision. • Balance competing demands across provider accounts, projects, and deadlines. • Work effectively with cross-functional teams within internal departments. Licensure: • Must have a valid driver’s license and car insurance.; ;

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.