Provider Network Operations Data Analyst

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.

*THIS IS A REMOTE POSITION BUT YOU MUST LIVE IN THE GREATER SOUTHFIELD, MI AREA*

Responsibilities:

The Provider Network Data Analyst is responsible for supporting the development of positive working relationships between Plan and its contracted and non-contracted providers for all products, Medicaid, Medicare and Exchange. The Provider Network Data Analyst I ensures that providers’ status with the health plan is represented correctly in all plan operating systems, functions as a pro-active practice account leader and coordinates resolution of provider issues

• Demonstrates a working knowledge and ability to explain Plan regulations, policies and procedures to providers. This requires the Provider Data Analyst I to stay current with all updates and revisions.
• Responsible for Monitoring and Managing Provider Network by assuring appropriate access to services throughout the Plan’s territory in keeping with State contract mandates.
• Responsible for provider data management
  
  • Maintaining a provider data change database documenting and tracking requests and monitoring processing turnaround time.
  • Responsible for data intake process including knowledge of relevant systems required to complete job functions.
  • Responsible for reviewing the data intake forms for accuracy and completeness.
  • Effectively and professionally communicate to all parties concerned the pertinent information required to execute quality services.
  • Responsible for escalating requests contrary to established business processes or contract language for resolution.
  • Demonstrates a functional knowledge of provider data and managed care provider reimbursement methodologies.
  • Knowledge of Managed Care concepts
  • Demonstrates ability to work independently.
  • Identifies, contacts and actively solicits qualified providers to participate in Plan at new and existing service areas, assuring financial integrity of the Plan is maintained and Contract
  • Management requirements are adhered to including language, terms and reimbursement requirements
  • Responsible for the accuracy and timely management of the provider contracts
• Supports, if requested, the credentialing and re-credentialing process, and the investigation of member complaints.
  
  • Obtains documentation required for credentialing for credentialing or re-credentialing of providers as requested.
  • Completes requests for investigation of member complaints within time period specified by Department standards.
  • Identifies and reports compliance issues in accordance with Plan policy and procedure.
• Demonstrates a functionally working knowledge of Facets, including the provider database and routinely relays information about additions, deletions or corrections to the Provider Maintenance Department.
• Works with all departments to develop and execute strategies for optimally managing medical costs.
• Administrative responsibilities:
  
  • Performs other duties and projects as assigned.
  • Adheres to Plan policies and procedures.
  • Attends required training sessions on an annual basis.

Education/Experience:

• Bachelor’s Degree or equivalent education with work experience required.
• One to two (1 - 2) years of Medicaid experience preferred.
• At least one (1) year in a Provider Services position. preferred.
• Three (3) years in the managed care/health insurance industry preferred.
• Experience with Excel spreadsheets (intermediate level) and MS Access.
• Analytical skills needed, but this is not an IT/IS Analyst job.
• Previous experience working with healthcare providers preferred.
• Previous provider relations experience preferred.

Diversity, Equity, and Inclusion

At Amerihealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

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.