AmeriHealth Caritas

Lead provider network development and management to meet organizational goals and improve provider satisfaction. | Requires extensive managed care provider contracting, Medicaid experience, and senior management skills. | For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement. 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 . Role Overview As the Director Provider Network Management, you will be responsible for all hospital, physician and physician extender network development and management, ensuring the team achieves annual goals and objectives. This position is also responsible for implementing strategies to improve provider satisfaction. In this role, you will collaborate with Hospital and Physician Practice Chief Executive Officers, Chief Financial Officers, Directors of Managed Care and other high level executives. Work Arrangement + Monday through Friday, 8:30 AM EST to 5:00 PM EST + Qualified candidates will reside in North Carolina Responsibilities + Responsible for strategic planning of hospital and physician network development and management. + Ensures compliance with pricing guidelines established by AHC and AmeriHealth Caritas North Carolina + Complies with established contract implementation process(s) for all contracts. + Ensures department staff remains current in all aspects of Federal and State rules, regulations, policies and procedures and creates or modifies departmental policies to reflect changes. + Ensures provider contracting is consistent with claim payment methodologies. + Responsible for implementation of electronic strategies for provider network to include increasing electronic claims submission and implementation of improved processes that result in increased auto-adjudication of claims. + Maintains familiarity with State Medicaid fee schedules and analyzes comparable Plan pricing guidelines. + Ensures provider contracting policies are adhered to as related to standard contract language. + Ensures that non-standard contract elements are communicated to appropriate departments and obtains AHC and Plan approval prior to submission to provider. + Responsible for compliance with network adequacy standards. + Ensures the provider network meets the health care needs of Plan members. + Establishes a recruitment plan, conducts recruiting activities and oversees the recruitment efforts of staff. + Augments and modifies the existing provider network to accommodate new products or clients as necessary. + Ensures provider communication and education meets AHC and Plan needs and functions as the liaison with the designated provider community. + Leads team in a manner conducive to ongoing growth and expanded knowledge of associates. + Coach team members in the use of data and appropriate analytical tools that support improved quality. + Support team members in the identification and creative problem resolution for improved processes and expanded use of technology. + Systematically keeps staff informed of policy and procedural changes affecting program and administrative operations. + Resolves individual provider complaints in a timely manner to ensure minimal disruption of the Plan’s network. + Ensures capitation, provider rosters, and RHC/FQHC reports are monitored and strategies are developed and plans are implemented to address outliers. + Drives Company-wide and Plan quality initiatives such as HEDIS, CAHPS and NCQA/URAC. + Ensures the achievement of financial, quality, and clinical objectives through accomplishment of provider initiatives. + Responsible for departmental staffing decisions and provides supervision to assigned staff, writes and performs annual reviews and monitors performance issues as they arise. + Regularly suggests innovative means of structuring operations in a fashion that helps alleviate backlogs and ensures the optimal utilization of resources. + Coordinates department’s efforts with those of other departments. + Reviews reports on annual provider satisfaction surveys; ensures the development of plans to improve identified areas of concern; works with other departments to develop quality assurance initiatives based on survey results. + Develops and ensures compliance of department budget. + Participates in Plan and physician committees as appropriate. + Performs other related duties and projects as assigned. + Adheres to AHC policies and procedures. Education and Experience + Bachelor’s Degree in business or health related disciplines such as Healthcare Administration or Healthcare management or equivalent business experience + Master’s Degree preferred + Minimum of 3 years Managed Care Provider Contracting and Reimbursement experience, including depth knowledge of reimbursement methodologies and contracting terms + Minimum of 1 year of Medicaid experience preferred + Minimum of 8 years of progressive business management and negotiation experience + Minimum 5 years management experience, managing teams and project management Licensure + A valid Driver’s License and current Auto Insurance required 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. As a company, we support internal diversity through: Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI. Remote About the Company: AmeriHealth Caritas Leaders in health care solutions for those most in need AmeriHealth Caritas is the nation's leader in providing comprehensive health care solutions for those in most need and the chronically ill. We impact the lives of more than 5.7 million members nationwide. With more than 30 years of experience managing care for individuals and families in publicly-funded programs, we have become known for developing innovative solutions that help improve health outcomes while reducing costs. Our mission, our goal Our mission is to help people get care, stay well and build healthy communities. Our goal is to provide responsible managed care solutions, including Medicaid, Medicare, and CHIP - plus behavioral health, pharmacy benefits management and third-party management and administrative services. Company Size: 5,000 to 9,999 employees Industry: Healthcare Services Founded: 1985 Website: http://www.amerihealthcaritas.com

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.