AmeriHealth Caritas jobs in Robbinsville, NJ - 52 jobs

**Role Overview:** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with regulatory requirements. This role involves outreach to appellants or their representatives, obtaining and reviewing medical records, packaging pertinent information into a case for determination, interacting directly with providers to obtain additional clinical information, and with members or their advocates to understand the full intent of the appeal. **Responsibilities:** + Process appeals, ensuring compliance with all regulatory milestones + Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation, billing code compliance, and prevent reimbursement errors + Outreach to appellants or their representatives to obtain and review medical records + Package pertinent information into a case for determination + Interact with providers to obtain additional clinical information + Engage with members or their advocates to understand the full intent of the appeal + Provide clinical expertise and determine medical necessity for case classifications when necessary + Perform front-line regulatory/compliance functions in the evaluation of appeals + Review appeal cases and ensure the Medical Director makes timely decisions + Review final determinations and create decision letters containing required information as regulatory entities dictate + Present cases to committees when necessary + Utilize InterQual criteria and apply them to appeals reviews + Stay current with the department and AmeriHealth Caritas policies and procedures + Familiarize yourself with and comply with federal, state, and local regulations, such as the National Committee Quality Assurance (NCQA) standards related to appeal and grievance operations **Education & Experience:** + Associate's degree in nursing (ASN) required + 3 or more years of experience in a related clinical setting and working with diagnosis procedure codes + Working knowledge of InterQual criteria + Proficiency in a Windows 10 environment and utilizing MS Office, including Word, Excel, and Outlook + Familiarity with the appeals process, preferably within a managed care organization **Licensure:** + Current and unrestricted Registered Nurse (RN) licensure or compact state licensure **Skills & Abilities:** + Strong verbal and written communication, critical thinking, presentation, and the ability to manage and complete multiple high-priority tasks within designated timeframes. Your career starts now. We're looking for the next generation of healthcare 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 healthcare 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, PA, 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 *************************** **Our Comprehensive Benefits Package** Flexible work solutions include 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.

The Vendor Management Business Analyst develops solutions to business problems and opportunities. Solutions may consist of process improvement as well as system development components. The Vendor Management Business Analyst works as a liaison among Vendors and Stakeholders in order to Elicit, Analyze, Communicate and Validate Requirements for changes to business processes, policies and information systems. The Analyst is the primary contact for Vendor related claims issues. The individual understands business problems and opportunities in the context of the "requirements" and recommends solutions that enable the organization to achieve its goals. **Responsibilities** + Develop solutions to business problems and opportunities through process improvements and system enhancements. + Act as a liaison between vendors and internal stakeholders to elicit, analyze, communicate, and validate requirements for changes to business processes, policies, and information systems. + Serve as the primary contact for vendor-related claims issues. + Understand business problems and recommend solutions that align with organizational goals. + Perform business analysis activities, which may include documentation, testing, training, and quality assurance as needed. **Education and Experience** + Required: Bachelor's degree or equivalent experience. + Preferred: Claims experience and familiarity with ACFC Claims Systems and processes. + 1-3 years of experience performing complex business analysis. + Ability to work independently and collaboratively within a team environment. **Skills** + Strong analytical and data-driven mindset. + Excellent communication and problem-solving skills. + Proficiency in business analysis methodologies and vendor management. + Familiarity with claims systems and processes. **Our Comprehensive Benefits Package** Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents starting Day 1, 401(k) retirement savings plan, tuition reimbursement, and more. **Why Join Us:** Your career starts now. We are looking for the next generation of healthcare 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 healthcare 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 are driven to make a difference, we want to hear from you. **About AmeriHealth Caritas** Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. Our services include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at ********************************* 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.

The Medical Director, Utilization Management, provides organizational leadership in the operational areas of appeals, utilization review, quality improvement, and related policy and practice initiatives in collaboration with the Corporate Medical Director(s), Utilization Management, and the Vice President, Medical Affairs. The following responsibilities are regarding enrollees with medical conditions and their providers: + Identifying and implementing evidence-based practice guidelines throughout the provider network. + Overseeing the quality of clinical care for network and non-network providers. + Engaging the provider network in Continuous Quality Improvement through the diffusion of practice standards and an internal quality assurance program that measures network provider performance against high-quality standards, especially the HEDIS program's performance standards. + Ensuring a high-performing Medical Management system that adheres to the terms of contracts and all relevant regulatory requirements. + Utilizing evidence-based standards in making coverage determinations. **Work Arrangement:** + Full Time Remote with required evening, weekend, and holiday coverage. **Accountabilities:** + Ensures quality and clinically sound services for all enrollees through associates and providers. + Serves as medical advisor and manager for all clinically related activities. + Ensures that the organization's medical policies and procedures adhere to contractual obligations. + Performs clinical case reviews in conjunction with the Medical Excellence Department. + Demonstrates knowledge of prescribed and established medical procedures and practices. + Maintains familiarity with federal, state, and local medical and clinical operations regulations. Provides leadership in developing and implementing medical policy related to health management, compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations. + Manages day-to-day operations and monitors the integration and processing of members to optimize the appropriate use of behavioral and physical health services. + Participates with Quality Improvement and Medical Excellence in identifying and analyzing medical and behavioral health information to develop interventions to improve the clinical effectiveness of medical management strategies. Work closely with a multidisciplinary team to ensure behavioral health management and quality management programs meet contractual obligations. + Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff. + Trains staff on medical issues and provides consultation to staff as appropriate. + Assists Care Managers in assessing members' needs for case management services and attends meetings and monthly rounds as scheduled. + Collaborates with the integrated case management team during scheduled meetings and informally as needed + Thoroughly documents all care coordination activity in the member's medical record in the electronic case management documentation system. **Education/Experience:** + MHA, MPH, or MBA in healthcare management preferred. + A minimum of three (3) years of utilization management or appeal experience in a Medicaid, Medicare, dual eligible, or commercial health plan is preferred. + A minimum of five (5 )years of clinical practice experience is required. + Experience working with Medicaid or Medicare preferred. + Proficiency utilizing MS Office (Word, Excel, Outlook), internet applications, and electronic medical record and documentation programs. **License Requirement:** + Doctor of Medicine (MD) or Doctor of Osteopathic Medicine licensed to practice as a medical director; additional state licensure required in all states where ACFC has a line of business, and that application is expected within 30 days of hire. + Current Pennsylvania license required, must be willing to obtain additional licenses where AmeriHealth Caritas has health plans. + Must be Board-certified in Family Medicine, Internal Medicine, Pediatrics, or Emergency Medicine. Must be clear of any sanctions by the applicable state or the Office of the Inspector General. + Must not be prohibited from participating in any Federally or state-funded healthcare programs. **Other Skills:** + Strong written and oral communication skills are 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. 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, Pennsylvania, 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 *************************** 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.

Your career starts now. We are looking for the next generation of health care leaders. **This position is remote however, you must live and be able to travel within Ohio as business needs.** At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nations 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 hear 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 *************************** The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC). **Major Accountabilities:** + Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations. + Conducts investigations of potential fraud, waste and/or abuse with a focus on thoroughness and attention to detail, quality, timeliness and cost control. + Conducts comprehensive interviews with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence. + Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrantclaims billing and practice patterns. + Analyzes data as part of the investigative process using available fraud detection software and corporate resources. + Represents ACFC in conducting settlement negotiations with providers, counsel and/or other associated parties. + Prepares and submits investigative reports covering all phases of the investigation. + Interprets and conveys highly technical information to others. + Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations. + Performs necessary functions to support all aspects of SIU investigations and responsibilities to include, but not limited to: Intake; Screening; Reviews; Referrals; Recoveries; and Provider Investigative Site Visits. **Education/ Experience:** + Bachelor's degree with a minimum of two years of experience in the healthcare field working in fraud, waste, and abuse investigations and audits OR + An associate's degree, with a minimum of four years of experience working in healthcare fraud, waste, and abuse investigations and audits. + Experience and training/certifications commensurate with position requirements in lieu of formal educational requirements for the Lead SIU Investigator position may be considered. + Valid driver's license required + Data Analytics experience preferred. + Ability to work independently with minimal supervision, and manage a high volume of assignments. + Strong verbal and written communication skills. + High degree of integrity and confidentiality required handling information that is considered personal and confidential. + Analytical skills and ability to make deductions; logical and sequential thinker. + A minimum of 3-5 years experience conducting comprehensive health care fraud investigations; interacting with state, federal and local law enforcement agencies. **Other Skills:** + Health care industry and/or Medicare/Medicaid/Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge required. + Clinical Experience preferred + SIU and/or State Medicaid regulatory compliancework experience preferred. + Knowledge and proficiency in claims adjudication standards & procedures preferred. + Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes. + Experience with decision support tools used for data analysis. + Advanced knowledge and experience working on various approaches to fraud, waste and abuse. + Working knowledge of Microsoft applications, especially Excel required. + Knowledge of available resources (internal and external) to assist in investigations. **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. 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.

Under the direction of a supervisor, the Utilization Management Reviewer evaluates medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical criteria. Using professional judgment, the Utilization Management Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient's needs in the least restrictive and most effective manner. **Work Arrangement** + Remote role + Monday through Friday from 8:00 AM to 5:30 PM EST + 4 out of 10 recognized company holidays to include Thanksgiving and Christmas (rotating) + Weekends based on business need **Responsibilities** + Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines + Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care + Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines + Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions + Identify and escalate complex cases requiring physician review or additional intervention + Ensure compliance with industry standards, including Medicare, Medicaid, and private payer requirements + Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment **Education & Experience** + Associate's Degree in Nursing (ASN) required; Bachelor's Degree in Nursing (BSN) preferred + Minimum of 3 years of diverse independent clinical practice experience to include Intensive Care Unit (ICU), Emergency Department (ED), Medical-Surgical (Med-Surg), Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC) settings + Minimum of 2 years of experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient and/or outpatient services + Experience conducting utilization management reviews for an insurance company (e.g. Medicaid, Medicare or commercial plan) is preferred **Licensure** + An active and unencumbered Registered Nurse (RN) license under the Nursing Licensure Compact (NLC) + Ability to obtain additional licensure across the enterprise to include the District of Columbia + Valid Driver's License **Skills and Abilities** + Competency in electronic medical record (EMR) documentation and charting + Proficiency using MS Office to include Word, Excel, Outlook and Teams + Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance + Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment + Maintains a strong working knowledge of federal, state, and organizational regulations to ensure consistent application in the review process + Accurate typing skills Your career starts now. We are looking for the next generation of healthcare 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. We want to connect with you if you want to make a difference. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with over 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 *************************** **Our Comprehensive Benefits Package** Flexible work solutions include 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.

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 nations 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 hear you. Headquartered in Newtown Square, Pennsylvania, 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 *************************** **Responsibilities:** The Utilization Management Tech functions under the direction of the Supervisor to coordinate, generate, and track both incoming and outgoing correspondence, faxes, and authorizations related to prospective, concurrent, and post-service review functions. Interacts with facilities, vendors, providers, and other staff to facilitate receipt of information and /or records for prompt review and response. Compensation plans for physicians, licensed nurse reviewers, staff, and consultants who conduct medical management do not contain incentives, directly or indirectly, that encourage barriers to care and service in making determinations. **Education/ Experience:** + High School/GED required. + Associate's Degree or equivalent education & experience preferred + Minimum of 1 year of general office and/or customer service experience preferred + Work experience in utilization management/review in a healthcare/MCO setting preferred + Knowledge of medical terminology preferred + Minimum of 1 year experience in Managed Care, Insurance, or Call Center preferred + Proficiency with Microsoft Office Suite (Word, Excel, PowerPoint) required **Our Comprehensive Benefits** 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.

Healthcare Value Optimization (HVO) is AmeriHealth Caritas' enterprise-wide margin improvement program, which delivers value for the organization through improved member experience, health outcomes, and total cost of care. HVO collaborates closely with functional and market leaders, following a rigorous process to identify, validate, implement, and monitor improvement initiatives across unique workstreams. The Performance Management Senior Analyst will support this program in driving value realization across the business through the delivery of initiatives and capabilities. Work Arrangement * This is HYBRID position. Associate will work in our beautiful Ellis Preserve office located in Newtown Square, PA at least three (3) days per week, including core days of Tuesday, Wednesday, and Thursday Responsibilities * Supporting Performance Management Director and collaborating with business leaders and other stakeholders to develop a robust business case by performing root cause analysis, gathering data, and resolving any issues or concerns * Identifying risks to implementation and sustainability of project outcomes and partner with business leads to develop mitigation strategy * Leading the planning and execution of key projects related to overall Performance Management goals by identifying and reinforcing project objectives, strategic considerations, and milestones * Helping create executive-level updates on projects to senior executives, and facilitate business leaders doing the same by collaborating to develop clear, top-down communications (e.g., PowerPoint presentations, memos, quick status updates) * Performing and presenting relevant analysis, trends, past/future activity, and conclusions to facilitate decision-making and drive value realization * Organizing raw data, running report queries, and analyzing data outputs to clearly communicate results * Assist in training other Performance Management Business Analysts Education and Experience * Bachelor's Degree * At least four (4)+ years of work experience in a collaborative, problem solving, or analytical field * Experience in synthesizing complex analysis, meeting deadlines and effectively communicating to leadership * Skilled in Microsoft Office * Ability to work effectively with people at all levels in an organization * Ability to manage progress of a strategic goal and ensure accountability of its success; ability to anticipate risks and manage accordingly * Strong entrepreneurial spirit and willingness to take initiative 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. 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 ***************************

**Quality Performance Specialist - Clinical** **As part of the Quality Management team, the Quality Performance Specialist - Clinical is responsible for leading and coordinating the clinical quality review process of member concerns and medical records utilizing standards of care. In addition, responsibilities also include supporting the annual medical record review activities including HEDIS and Clinical Practice Guidelines. The position also supports accreditation and clinical quality performance improvement activities.** **Responsibilities:** **Assist with accreditation and clinical quality performance improvement initiatives.** **Conduct quality-of-care reviews, including sentinel events and member concerns; collaborate with physician advisors and clinical quality committees.** **Collect and organize necessary medical records for clinical review; summarize findings for committee review.** **Prepare and manage Quality Assessment and Performance Improvement (QAPI) meeting materials, including packets, schedules, agendas, and minutes.** **Review and approve the annual Quality Management (QM) work plan, including performance measures, goals, objectives, and thresholds.** **Recommend new or improved QM activities using Plan-Do-Study-Act (PDSA) cycles.** **Develop quarterly Quality of Care (QOC) trending reports for QAPI and follow up on recommendations.** **Ensure compliance with QM policies, including annual reviews, updates, and approvals.** **Participate in activities and reporting to maintain compliance with state regulations and NCQA standards.** **Collaborate with the Quality Improvement Department on annual medical record review activities, including tool development, staff training, testing, and auditing.** **Perform other duties as assigned.** **Education & Experience:** **Associate's Degree or equivalent experience required; Bachelor's Degree preferred.** **Minimum 3 years of experience in clinical or service quality improvement, healthcare delivery, or related field.** **Active, unrestricted clinical license (RN)** **Prior experience in project facilitation or management preferred.** **Knowledge of Quality Improvement (QI) functions in a Managed Care Organization (MCO) preferred.** **Familiarity with Medicaid and Medicare programs preferred.** **Proficiency in Microsoft Office Suite (Word, PowerPoint, Excel) required.** **Our Comprehensive Benefits Package:** We offer flexible work solutions, including remote options and hybrid schedules, competitive pay, paid time off (including holidays and volunteer events), health insurance coverage for you and your dependents starting Day 1, 401(k), tuition reimbursement, and more. **About AmeriHealth Caritas:** Your career starts now. We're 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 millions of lives through our national footprint of products, services, and award-winning programs. Headquarters in Newtown Square, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. Our services include integrated managed care products, pharmacy benefit management, specialty pharmacy services, behavioral health services, and other administrative solutions. Discover more about us at ****************************** 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.

Healthcare Value Optimization (HVO) is AmeriHealth Caritas' enterprise-wide margin improvement program, which delivers value for the organization through improved member experience, health outcomes, and total cost of care. HVO collaborates closely with functional and market leaders, following a rigorous process to identify, validate, implement, and monitor improvement initiatives across unique workstreams. The Manager position ensures successful execution of margin improvement activities through thought leadership, cross-functional coordination, and proactive problem-solving. The Manager also develops, defines, and communicates best practices for driving continuous improvement of the HVO program. **Work Arrangement** + This is a hybrid, office based position located at our Ellis Preserve in Newtown Square office. Core office days are Tuesday, Wednesday, and Thursday. Remote days are Monday and Friday **Responsibilities** + Drive process, performance management, and execution of margin improvement initiatives through the HVO stage gate framework + Monitor overall program and workstream status, proactively identifying risks/issues and other areas requiring escalation, problem solving, or expert input + Motivate and support workstream leaders and initiative owners to deliver, driving accountability to annual targets + Provide an objective sounding board to initiative owners and offer data-backed recommendations and guidance + Identify opportunities for new initiatives by recognizing organizational pain points, reviewing emerging trends, or researching industry developments + Apply working knowledge of key financial and operational performance indicators for target markets / functions + Prioritize effectively across initiatives and workstreams to best allocate resources + Lead departmental efforts to drive continuous improvement across the HVO program + Support governance activities including policies, procedures, and operational guidance for the program + Manage daily/weekly meeting cadence and regular deliverables (e.g., pipeline reporting) **Education and Experience** + Five to ten (5 - 10) years of experience in designing, implementing, and monitoring broad-scale, cross-enterprise initiatives + Strong analytical capabilities, including ability to craft ROI estimates + Ability to manage multiple tasks simultaneously, proactively assessing initiative status and highlighting issues + Strong verbal and written communication skills + Proficiency in Microsoft PowerPoint and Excel + Familiarity with Managed Care Organization operations preferred + Bachelor's Degree or equivalent experience **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. Your career starts now. We're looking for the next generation of healthcare 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 healthcare 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 ************************** . 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.

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 ************************** . **Job Summary** The Appeals & Grievance Case Resolution Specialist is responsible for the full life cycle of assigned member and/or provider appeals and grievance cases. Working under general supervision, this role conducts case intake, investigation, and documentation to ensure accurate and timely resolution consistent with federal state, and accreditation standards. The Specialist serves as a key liaison between members, providers, and internal departments to resolve issues effectively, ensuring the integrity of the appeals and grievance process and compliance with CMS, NCQA, URAC, and state regulatory requirements. **Essential Functions** **_Case Management_** + Research and analyze case documentation, including benefit coverage, prior authorizations, claims, and regulatory guidance. + Communicate with members, providers, or representative to clarify appeal intent and gather missing documentation including incoming calls, outgoing calls, and phone queue work as assigned. + Prepare complete and compliant case files, ensuring all required documentation is included. + Track case progress and maintain compliance with turnaround times and documentation standards. + Generate accurate and timely determination and acknowledgement letters. **_Investigation and Resolution_** + Collaborate with internal departments such as Claims, Medical Management, Legal, and Compliance to obtain necessary information for resolution. + Identify potential compliance issues or risk factors requiring escalation. + Participate in case discussions, internal committee reviews, or external fair hearing preparation as assigned. + Document all activities, correspondence, and outcomes in the case management system with attention to detail and accuracy. **_Compliance & Quality_** + Ensure case handling meets all application federal and state regulatory requirements, including with CMS, NCQA, and URAC. + Maintain confidentiality and protect member information in compliance with HIPPA regulations. + Identify opportunities for process improvements to enhance quality and efficiency. **_Team Collaboration_** + Serve as a resource to peers and administrators for routine case-related questions. + Maintain professional communication with members, providers, and internal stakeholders. + Participate in team meetings and contribute to continuous improvement initiatives. **Education/Experience** + Associate's Degree: in Health Administration, Business, or related field required Preferred Experience Level: + Knowledge of medical terminology, benefit interpretation, and regulatory processes preferred. Prior experience working with CMS, Medicaid, or state-regulated appeals processes preferred. + 2 to 3 years experience in healthcare operations, managed care, or grievance/appeals coordination. **Other Skills** + Proficiency in Microsoft Office Suite (Word, Excel, Outlook, etc.). + Strong attention to detail and organization. + Excellent written and verbal communication. + Ability to manage multiple priorities in a fast-paced environment. + Strong analytical and problem-solving abilities. + Customer service orientation with professional communication etiquette. **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.

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 *************************** The Provider Network Data Oversight Analyst performs the role of payment terms data source expert to support AmeriHealth Caritas nationwide across all products. They are responsible for oversight and validation of information from multiple external and internal sources and departments, assuring accuracy and validity while crystallizing results in recommendations. They independently manage multiple projects including the development of the business logic for the subsequent creation of standard queries and reporting. Under the direction of the Vice President - Network Pricing, provides analytical support to the Provider Network Management team by performing analysis of provider data, payment term changes, and general configuration. Responsibilities: * Collaborates with Actuarial, Network, and Operational areas to develop lenses that provide event triggered output for monitoring of impending contract changes and provider patterns. * Effectively prioritizes and communicates insights and recommendations. * Facilitates partnerships with Vendors, IT, Payment Systems, Operations Services, Provider Network Management, Market, and Clinical teams as needed to research financial issues, risks, and opportunities related to fee schedules, chargemasters, contract terms, and outliers. * Manages issue-tracking database to ensure that challenges are resolved within established timeframes and escalates open issues as needed. * Defines, develops, and/or implements data modeling tools or reports designed to routinely assess and support existing and new provider network management processes, programs, contract performance, and proposed initiatives, such as fee schedule development, provider contract interpretation' and system interfaces/integration. Education / Experience: * Bachelor's Degree required. * At least four (4) years of Analytics experience. * Advanced Microsoft Excel experience required. * Experience with SQL and BI Tools such as Power BI or Tableau required. * Superior analytical skills including the use of very large data sets; ability to recognize anomalies in findings, and pursue and/or recommend resolution. * Ability to work with integrated data from multiple sources. * Other relevant experience includes work with Databricks, SAS, Python, and R. * Demonstrated ability in effectively interfacing with key leaders and stakeholders both internal and external to the organization to research technical and/or operational issues and define solutions. * Must have excellent communication skills. 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.

The Senior Creative Project Manager is responsible for managing the end-to-end lifecycle of complex, large-scale creative projects for AmeriHealth Caritas' in-house creative agency. This role is tasked with overseeing ambiguous, cross-functional, multi-channel, integrated creative campaigns and requires a strategic thinker with a deep understanding of creative project management methodology, exceptional organizational skills, and the ability to navigate uncertainty. The ideal candidate will function as the primary point of contact for stakeholder's post creative kickoff and informally leads teams of creative resources through discovery, creative development, and implementation of creative projects. Work Arrangement: This position is a hybrid position 3 days a week at our Ellis Preserve headquarters. Essential Functions * Lead teams of cross-functional resources providing direction and support to ensure timely project completion of complex, multi-channel, integrated creative campaigns adhering to SLA standards and ensure compliance with all AmeriHealth Caritas and Creative Services and Brand processes. * Serve as the point of contact for stakeholders after creative kick-off, regularly communicating project status and managing stakeholder expectations. * Identify project risks, issues, and scope creep; provide mitigation strategies and issue change order requests to keep the project on track or renegotiate timelines. * Utilize Workfront to build, track, and manage project timelines, resource allocations, task durations, and related project details for our most complex, ambiguous, creative campaigns. * Continuously educate stakeholders and partners on creative processes and ensure accountability to agreed upon review timeframes. * Partner with Creative Strategists to ensure alignment on project goals, stakeholder expectations, and strategic direction throughout the project lifecycle, and collaboratively manage and address scope creep. * Use data-driven decision making to identify opportunities for continuous improvement, shape creative project management best practices, develop SOPs, training materials, and serve as subject matter expert for project management and agency best practices. * Facilitate creative kickoffs, reviews, retrospectives, and other meetings as necessary capturing notes and recapping next steps and actions for distribution. Education/Experience * Bachelor's Degree: Project Management, Marketing, Business, or a related field. * 5 to 8 years experience in project management within a creative agency or corporate creative/marketing team. Other Skills: * Proven track record of managing large-scale, complex, multi-channel, integrated creative campaigns. * Proficiency in Workfront or similar project management tool (e.g., Smartsheet, Wrike, Asana, or similar). * Strong understanding of how shifting project schedules can affect resource management capacity and utilization. * Exceptional organization skills and attention to detail. * Ability to act with urgency and prioritize effectively. * Excellent communication and interpersonal skills. * Proven ability to manage multiple projects simultaneously and deliver high-quality results. * Ability to manage and push back on scope creep and manage stakeholder expectations. * Knowledge of KPI tracking and performance metrics. * Achieves outcomes with and through others. * Prior project management of traditional and digital marketing materials. 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. 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 ***************************

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 ************************** . **Responsibilities:** The Committee Meeting Coordinator is responsible for supporting member appeal committee meeting scheduling and support activities. + Works within the Clinical Appeals area and ensures that member and participant (LTSS) committee meetings have the appropriate representation and are scheduled within the contractual required period. + Responsible for scheduling the committee date, time and desired meeting format (telephonic, videoconference or in-person) with the member, participant and any third-party representatives. + Schedules other required committee members as dictated by department policies. + Processes any changes as requested by the member, participant or other committee member once meetings are scheduled. + Enters appropriate data into the Appeals Scheduling Tool. + Provides other Appeals support including assisting, when necessary the area Transcriptionist with recorded dictation of doctor or other healthcare professional, transcribe and interpret the dictation of the Appeals panel meeting and upload to the Member record, review and edit drafts prepared by speech recognition software and translate medical abbreviations and jargon into the appropriate long form. **Education/ Experience:** + High SchoolDiploma or GED required. + 1 to 3 years of experience providing support to a clinical team by scheduling meetings, transcribing meeting notes, maintaining records, etc. within a fast paced environment with tight deadlines. + Prior Customer Service experience; the ability to speak with members and/ representative face to face and telephonically. + Ability to write and distribute detailed notes in a timely fashion. + Familiar with the member/provider appeal process (for supported areas) in a managed care organization is a plus. + Proficient PC skills in a Windows based environment including word processing, spread sheets and working in database programs. + Proven ability to keep accurate and timely records and documentation according to established processes. **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.

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 ************************** . **Job Summary** We are seeking a highly skilled and strategic Director of Benefits to lead and evolve the design, implementation, and management of our organization's comprehensive benefits and retirement programs. This role owns the benefits strategy and execution, ensuring alignment with organizational objectives and full compliance with legal and regulatory requirements. The ideal candidate is a thought leader with a proven track record in health benefits management, deep expertise in retirement plan administration (401(k), non-qualified, and pension), and a passion for driving innovative solutions that enhance employee engagement, experience, and financial wellness. **Essential Functions** Strategy & Leadership + Develop and execute benefits strategies that support organizational goals and employee needs. + Partner with HR leadership and executive teams to set plan design and direction for health, welfare, and retirement benefits. + Lead and mentor a team of HR professionals, fostering growth and development. Benefits Administration + Oversee the design, implementation, communication, and administration of health and welfare programs, including, COBRA and wellness initiatives. + Oversee the management and ensure full compliance in the administration of the organization's leave programs, including but not limited to ADA, FMLA, Disability, and Workers' Compensation. + Manage qualified and non-qualified 401(k) plans and defined benefit pension plans, ensuring regulatory compliance. Wellness & Engagement + Design and implement strategic wellness programs to improve employee health, engagement, and cost containment. + Monitor market trends and best practices to continuously enhance wellness offerings. Compliance & Vendor Management + Ensure compliance with all federal and state regulations (ERISA, COBRA, HIPAA, ACA, IRS, DOL), including non-discrimination testing and federal filings. + Direct vendor management and contract negotiations to optimize service and cost efficiency. Program Innovation + Lead the evolution of our benefits portfolio, introducing progressive, inclusive, and relevant offerings that support the whole person. + Conduct annual benchmarking and participate in industry surveys to identify alternative benefit options and prepare recommendations for senior leadership. + Analyze program effectiveness and develop strategies to enhance impact and employee experience. **Other Duties** + Oversee analysis and reporting related to benefits utilization. + Lead other related projects as assigned. **Education/Experience:** + Bachelor's Degree. + Master's Degree or professional certifications (e.g., CEBS, SPHR, CRPS, or, CPF) preferred but not required. or professional certifications (e.g., CEBS, SPHR, CRPS, or CFP) preferred but not required. + Preferred Experience Level (if different from minimum required): 12 + years of experience in benefits administration, with a strong focus on strategic benefit design and implementation. + 12+ years of experience in benefits administration, with a strong focus on strategic benefit design and implementation + 10 or more years experience. **Job Related Skills:** + In-depth knowledge of ERISA, ACA, FMLA, HIPAA, COBRA as well as IRS and DOL regulations governing retirement and health plans. + Proven ability to develop and execute strategic benefits programs that balance organizational goals and employee needs. + Exceptional analytical, problem-solving, and project management skills. + Strong interpersonal and communication skills with the ability to influence and collaborate across all levels of an organization. + Experience managing vendor relationships and negotiating contracts to ensure optimal service and cost efficiency. **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.

**Responsibilities:** Under the general supervisor of the Manager Accounts Receivable, the analyst is responsible for identifying, validating, submitting and reconciling all maternity submissions accurately and timely for all applicable lines of business. Based on State specific methodology and timeframes- i.e. weekly, monthly; accurately submit maternity delivery data via Newborn/Maternity Tracking Tool for creation of 837P: + Accurately submit maternity delivery data via state web portals for individual maternity submissions; while also updating Newborn/Maternity Tracking Tool keeping systems in unison. + Ability to retain multiple sets of maternity criteria, medical billing logic and maternity mapping logic. + Responsible for Newborn//Maternity Tracking Tool system updates of ICD-10, Diagnosis codes, CPT, DRG, and procedure codes; Modifiers, Part A codes and Revenue rate data. + Be fluent with existing and new 820, 835 and 837P companion guides, system notices and or maternity documentation, adherence to requirements; advise management on needed actions to comply with state requirements as they occur. + Prepare EDI 820 premium payment files, EDI 835 maternity payment files and Adhoc files for data mapping documents at a column level from source columns mapped to appropriate target columns. + Continuous enhancement recommendations of Newborn/ Maternity Tracking tool for all plans. + Actively participates in Q/A of Newborn/Maternity tracking tool user acceptance testing functions, such as test script development, testing and documentation of test results. + Develops and maintains a complete understanding of all data sources (including, but not limited to the Data Warehouse, the Facets System and the NBTT) available for reporting so that research and analysis can be completed on discrepancies. + Responsible for meeting all monthly/ quarterly deadlines and provides full support to other areas such as Accounting, EDI, Enrollment, Encounters, Healthcare Apps, Statutory and the Actuarial departments. + Generates and updates reports for monthly maternity reconciliation, aging reports, financial audits and all other required reporting; Analyzes completed reports to ensure there are no material differences that should be escalated to management for review. + Maintains and creates maternity databases, queries, joins, tables and forms; designs and creates SQL stored procedures, technical specifications and user-defined functions, writing functional and technical specification documents. + Participates in the completion of all designated annual goals for the Financial Services department. + Communicates with management/stakeholders to determine appropriate courses of action prior to enacting changes in reporting processes. + Prepare for onsite audits of all tasks requiring process explanation and accountability. **Education/Experience:** + Bachelors' degree required. + 1 to 3 years knowledge of medical billing ICD-10, CPT DRG claims coding Revenue Code Mapping, Data Analysis, Data warehousing, translated 5010 EDI files, financial reporting and related financial analysis experience. + Basic understanding of Claims Processing / Clinical Coding and business practices. + Basic working knowledge of business computer programs, applications and systems, database structures and data files required. + 2 years experience in healthcare finance and/or financial reporting, preferred. + Strong communication (both written and verbal), analytical and problem solving skills. + Excellent organizational skills. + Ability to work on multiple tasks with competing priorities; demonstrates strong subject matter expertise in the states and business processes that they support. + Ability to work accurately and independently as well as comfortable interacting collaboratively with all levels of business; open mind to consider alternative ideas and next steps for remediation. **Other Skills:** + Efficient in Microsoft SQL Server, Oracle, My SQL, SQL Server Reporting Services. + Proficiency in Excel, Access, preferred. **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. 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 Philadelphia, 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 ************************** . 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.

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. Discover more about us at ************************** . **Work Arrangement:** This is a hybrid position located in our Newtown Square, PA headquarters. Three days per week are required onsite. **Job Summary** Reporting to the EVP, Chief Human Resources Officer, the Vice President, Human Resources Technology & Operations is a transformative, engaging leader responsible for reimagining and executing a modern, scalable Human Resources (HR) systems and operations strategy. This role will drive the creation of a best-in-class HR shared services model, oversee the selection, implementation, and change management of modernized HR technology platforms, and enable data-driven decision making through advanced HR analytics capabilities. **Key Responsibilities** **HRIS Strategy & Technology Transformation** + Own the vision, roadmap and execution of the HR Technology strategy, including the evaluation, selection and implementation of a new Human Capital Management (HCM) platform. + Oversee HR systems integration, data integrity, configuration and security in collaboration with IT and vendors. + Ensure scalable system design to support enterprise growth and evolving workforce needs. **HR Operations & Shared Services Transformation** + Lead the strategic design and buildout of a centralized HR Operations function with a shared services delivery model. + Establish consistent, scalable processes and service level agreements across all HR operational areas. + Implement operational excellence methodologies to improve service delivery, compliance and associate experience. + Drive automation and self-service initiatives to streamline HR service delivery. **HR Data, Reporting & Analytics** + Build and lead an HR analytics function to enable real time reporting, dashboards and predictive insights talent management, workforce planning inclusion and belonging, and more. + Partner with key stakeholders to define KPIs and design metric frameworks. + Ensure data accuracy, compliance and privacy in alignment with legal and regulatory requirements. **Education & Experience** + Bachelor's Degree in Human Resources, Information Systems, Business Administration, or a related field is required. + Master's Degree is preferred. + 15+ years of progressive HR experience is required. + 7+ years of experience in HRIS/Operations leadership is required. + Proven experience leading a large scale HCM implementation is required. + Proficiency in modern HRIS platforms, data analytics tools (e.g. Tableau, Power BI, etc.) and project management tools. + Preferred certifications include HRIP, PMP, or SHRM-CP/SHRM-SCP. **Job-Related Skills:** + **Strategic Thinking** : Ability to align HRIS and Shared Services initiatives with long-term business and HR goals. + **Leadership and Team Management** : Exceptional leadership, communication and change management skills. + **Technical Expertise** : Deep knowledge of HR processes across the employee lifecycle. Strong analytical orientation with a track record of building or expanding HR reporting and analytic functions. + **Project and Change Management:** Proficiency in managing complex projects and leading large change management initiatives to ensure smooth transitions and system and process adoption. + **Communication and Collaboration** : Exceptional ability to engage with cross-functional stakeholders, translate technical concepts, and foster partnerships across teams. **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.

**Role Overview:** The Contract Specialist connects our team, the health plan, and key stakeholders. This role focuses on building and maintaining collaborative relationships while ensuring contract data and documents are accurately reflected across systems. Responsibilities include hands-on contract administration, issue resolution during contract loading, and maintaining compliance standards. **Work Arrangement** : Remote; Anywhere within the continental U.S. **Responsibilities** + Build and maintain positive relationships with internal teams, health plans, and stakeholders. + Ensure contract data and documents are accurately represented in operating systems. + Act as a proactive contract administrator, resolving contract-related issues. + Audit contract documents and provider records for accuracy. + Manage and monitor Excel reports for projects and assignments. + Create and align contract records in the contract management system with 95% accuracy. + Monitor electronic contract files and ensure compliance with policies. + Escalate requests that conflict with business processes or contract language. + Support departments in investigating provider data and credentialing. + Research and resolve discrepancies in data and documentation. + Identify and report compliance issues. + Maintain knowledge of Facets or other claims systems and communicate contract corrections. + Communicate effectively and professionally with all parties. + Collaborate with departments to execute AmeriHealth and health plan strategies. + Perform administrative duties and attend required training sessions. + Stay current on AmeriHealth and health plan regulations, policies, and procedures. **Education & Experience** + High School diploma or GED required; Bachelor's degree preferred. + 1-2 years of experience in provider network management, finance operations, contract management, or contract administration within healthcare or managed care. + Experience with contracting software (e.g., Portico, McKesson, Conga, Salesforce). + 1-2 years of managed care experience required. **Our Comprehensive Benefits Package** Flexible work solutions including hybrid work schedules, competitive pay, paid time off including holidays and volunteer events, health insurance coverage for you and your dependents, 401(k), tuition reimbursement, and more. 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 on 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 hear from you. Headquarters 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. 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.

Under the direction of a supervisor, the Utilization Management Reviewer evaluates medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical criteria. Using professional judgment, the Utilization Management Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient's needs in the least restrictive and most effective manner. **Work Arrangement** + Remote role + Monday through Friday from 8:00 AM EST to 5:00 PM EST + Must work 4 recognized company holidays to include Thanksgiving and Christmas (rotating) + Weekends and overtime based on business need **Responsibilities** + Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines + Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care + Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines + Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions + Identify and escalate complex cases requiring physician review or additional intervention + Ensure compliance with industry standards, including Medicare, Medicaid, and private payer requirements + Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment **Education & Experience** + Associate's Degree in Nursing (ASN) required; Bachelor's Degree in Nursing (BSN) preferred + Minimum of 3 years of diverse independent clinical practice experience as a Registered Nurse in outpatient surgery, Medical-Surgical, Critical Care, Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC) settings + Experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient, outpatient and/or post acute services + Experience conducting utilization management reviews specific to a Medicare population across multiple states for a payer preferred **Licensure** + An active and unencumbered Registered Nurse (RN) license + Valid Driver's License **Skills and Abilities** + Competency in electronic medical record (EMR) documentation and charting + Proficiency using MS Office to include Word, Excel, Outlook and Teams + Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance + Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment + Maintains a strong working knowledge of federal, state, and organizational regulations to ensure consistent application in the review process + Ability to type with accuracy and speed Your career starts now. We are looking for the next generation of healthcare 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. We want to connect with you if you want to make a difference. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with over 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 *************************** **Our Comprehensive Benefits Package** Flexible work solutions include 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.

**Role Overview:** The Director of Network Adequacy leads the strategic integration and utilization of provider network adequacy, availability, and access data to drive network optimization and improvement. Oversee a team responsible for delivering analysis and reporting that ensures both existing and emerging markets meet geographic access and availability standards in alignment with state contract requirements. Leverages internal and external data sources to identify network gaps and collaborates with the network management team to implement effective remediation strategies. **Work Arrangement:** + Remote - Associate can be located anywhere in the United States. **Responsibilities:** + Develop and execute business intelligence requirements to manage and validate provider information and ensure data integrity in Facets and Market Data Libraries across the contracting continuum Request for Proposal (RFPs), new markets, new products, market expansions, and re-procurements). + Design, implement, and document business and reporting processes, programs, policies, and procedures to support transition to market plan operations and meet regulatory reporting requirements. + Model and drive network development opportunities throughout the contracting lifecycle to address network gaps, implement remediation plans, and support alternative delivery systems while ensuring regulatory and contractual compliance. + Interpret and apply access and adequacy standards for growth and existing markets in compliance with state and federal contracts, configuration requirements, and reporting obligations. + Analyze and interpret network adequacy data by collecting, sorting, and evaluating information, blending business and network expertise with strong analytical skills. + Collaborate across functional areas to identify issues, communicate with executives, and develop strategic action plans related to adequacy, geographic access, network development, and business intelligence. Key partners include Network Management, Provider Enrollment, Market Entry, New Business Development/Growth Markets, and IS stakeholders. **Education & Experience:** + Bachelor's degree required; Master's degree preferred + 10 plus years of relevant experience in healthcare networks, analytics, business intelligence, market development, or related fields + Proven ability to lead teams, manage complex datasets, and interpret regulatory requirements **Skills & Abilities:** + Excellent written and oral presentation/communication skills + Experience working in matrixed environments + Effective leadership and analytical skills + Ability to work collaboratively with internal and external stakeholders 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.