Lead the development and execution of the enterprise strategic plan and annual business plan to advise the CEO and Executive Council. Manage strategic growth initiatives, evaluate M&A opportunities, and lead a team in executing key corporate projects.
Amerihealth Caritas
68 Remote Job Openings at Amerihealth Caritas
Director of Strategy & Product Develop
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
Lead the end-to-end strategy, design, and lifecycle management of ACA-compliant health insurance products. Partner with the President of Exchange Markets to develop segment-level business strategies and actionable roadmaps for sustainable growth.
Coordinate long-term services and supports for Medicaid participants through face-to-face assessments and participant-centered planning. Manage the delivery of physical, behavioral, and social services while ensuring participants are informed of their rights and options.
MDM / ERDM Business Systems Analyst Senior
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
The role serves as a Subject Matter Expert providing business analysis support for Member and Provider MDM and ERDM initiatives. Responsibilities include leading requirements management, performing hands-on data analysis using SQL and Databricks, and acting as a liaison between business and technical teams.
Lead the launch, growth, and overall operational performance of the Indiana health plan. Serve as the primary market-facing leader to build relationships with state agencies, providers, and community partners.
Vice President Provider Network Management
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
The Vice President leads enterprise-wide provider contracting and network management strategy to ensure high-performing, compliant networks. This role oversees the Indiana provider network strategy and collaborates across business functions to align network growth with organizational goals.
Family Medicine Medical Director Utilization Management
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
Lead operational areas of the Utilization Management program, including prospective, concurrent, and retrospective reviews to ensure medically appropriate patient care. Collaborate with multidisciplinary teams to develop medical policies and analyze utilization trends to improve clinical effectiveness.
The Associate Actuary provides support for rate advocacy, manages financial forecast models, and analyzes medical and pharmacy cost drivers. They are responsible for developing actuarial models and communicating results to various stakeholders while adhering to professional standards.
Supports daily operations of integrated care and utilization management programs within a contact center environment. Provides members with educational materials and strategies to increase healthcare adherence and reduce barriers to care.
The Care Connector supports daily operations of integrated care and utilization management programs within a contact center environment. They provide members with educational materials and implement strategies to increase healthcare adherence and reduce barriers to care.
Network Contractor Provider Network Management
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
The Network Contractor is responsible for recruiting, contracting, and re-contracting healthcare providers to ensure a compliant and marketable network. This includes negotiating rates, managing provider satisfaction, and aligning contracts with federal and state regulations.
Director Quality and HEDIS Data Strategy
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
Lead the strategic acquisition, ingestion, and integration of population health data to support enterprise quality programs. Collaborate with IS and provider partners to implement data interoperability and digital measure reporting across the healthcare ecosystem.
Manager Coordination of Benefits Oversight
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
Oversee end-to-end subrogation case management and Coordination of Benefits (COB) processes to ensure payment integrity. Manage vendor performance, ensure regulatory compliance for Medicaid and Medicare, and lead a team of specialists and analysts.
The role focuses on producing and presenting performance reports and VBC models to improve provider network efficiencies. It involves collaborating with providers to address gaps in care and implementing quality improvement strategies based on HEDIS and TCOC metrics.
Manager, Behavioral Health Clinical Liaison/Operations
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
Lead the development and implementation of integrated physical and behavioral healthcare programs to improve service delivery and health equity. Act as a clinical liaison between internal departments, executive leadership, and external stakeholders to coordinate complex member care.
Appeals & Grievance Case Resolution Specialist
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
Manage the full life cycle of member and provider appeals and grievance cases through intake, investigation, and documentation. Act as a liaison between internal departments and external stakeholders to ensure timely resolution compliant with federal and state standards.
Payment Integrity Client & Vendor Management Manager
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
Manage relationships and oversight for Population Health and Payment Integrity vendors to maximize value and minimize risk. Coordinate client meetings, track issue repositories, and ensure compliance with regulatory standards.
Manager Integrated Care Management
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
Leads the day-to-day operations of the Integrated Care Management team and oversees the development and performance of clinical care management programs. Collaborates with business lines to ensure compliance with NCQA standards and state and federal laws.
Manage the end-to-end print and postage process, including mail merges, PDF conversions, and quality control of letter output. Coordinate print projects to meet client SLAs and identify opportunities for production efficiency.
Coordinate long-term services and supports for Medicaid participants through face-to-face assessments and participant-centered planning. Manage the delivery of medical, social, and behavioral health services while ensuring participants are aware of their rights and options.
Develop large reporting layers, executive decks, and metrics to support the Total Cost of Care revenue and expense review process. Collaborate with operational partners to identify high-value opportunities for savings and revenue growth.
The Care Connector supports integrated care and utilization management by processing calls from members and providers in a contact center environment. They provide educational materials and implement strategies to improve healthcare adherence and reduce barriers to care.
The Care Connector supports integrated care and utilization management by processing calls from members and providers in a contact center environment. They provide educational materials and implement strategies to improve healthcare adherence and reduce barriers to care.
The Senior Actuarial Analyst provides actuarial services across Medicaid markets, valuation, or analytics teams. Key duties include calculating fee schedule impacts, updating reserve models, and performing medical cost projections for budgeting.
Coordinate long-term services and supports for Medicaid participants through face-to-face assessments and participant-centered planning. Manage the delivery of physical, behavioral, and social health services while ensuring participants are informed of their rights and options.
The Clinical Appeals Reviewer processes appeals and ensures compliance with regulatory milestones by reviewing medical records and determining medical necessity. This role involves coordinating with providers, members, and advocates to gather clinical information and prepare cases for final determination.
Leads the development and execution of capture plans for Medicaid and related business RFX efforts. Manages cross-functional teams and external consultants to identify customer needs and develop winning strategic solutions.
Lead the strategic direction and operational execution of care coordination and population health programs within the Michigan market. Oversee multidisciplinary clinical teams to ensure high-quality, compliant, and member-centered services aligned with state and federal requirements.
Lead a team of technical leads and architects to oversee critical enterprise integration and API platforms. Drive the modernization of platforms using cloud-native practices, API-first strategies, and AI-driven automation.
Audit and analyze Facets configuration changes to ensure accuracy and completeness of documentation. Build complex queries to validate production migrations and analyze affected claims to ensure accurate outcomes.
Draft and refine narrative sections for state Medicaid managed care bids, translating technical information into compliant and compelling prose. Collaborate with subject matter experts and utilize AI-enabled tools to produce high-quality, evaluable proposal responses.
Lead the daily operations of the proposal writing team, managing assignments and timelines for state Medicaid managed care bids. Coach writers and personally draft high-visibility sections to ensure compliant, persuasive, and evaluable responses.
Coordinate long-term services and supports for Medicaid participants through face-to-face assessments and participant-centered planning. Manage the delivery of physical, behavioral, and social health services while ensuring participants are informed of their rights and options.
Leads the enterprise writing strategy for Medicaid and government-sponsored health program bids to improve quality and win rates. Manages a team of writers and editorial staff while serving as the editor-in-chief for priority proposals.
Design, develop, and implement cost-effective software solutions and applications using SQL Server and ETL tools to support Medicare operations. Interface with stakeholders to translate business requirements into technical specifications and maintain system architecture.
The Senior Community Care Manager coordinates community-based care and case management for high-risk members, including conducting in-home assessments and developing individualized care plans. They also serve as a subject matter expert, mentoring team members and ensuring compliance with NCQA and URAC standards.
Oversee and implement clinical quality initiatives by utilizing data analytics to identify root causes and execute improvement plans. Manage activities related to plan accreditation, preventive health, and clinical service quality including HEDIS and CAHPS.
Develop and maintain strong relationships with healthcare providers to drive performance in risk-based and cost-sharing value-based care arrangements. Manage network development, resolve provider disputes, and oversee joint operating committees for health systems.
Lead the design and architecture of next-generation Member Engagement capabilities on the Salesforce platform. Provide technical guidance, establish architectural standards, and collaborate with enterprise architects to deliver scalable CRM solutions.
Lead the development of complex, scenario-based narratives and high-visibility sections for state Medicaid managed care bids. Collaborate with subject matter experts and leadership to translate technical operational details into compelling, compliant, and evaluable prose.
The role focuses on managing contract data and documents to ensure accuracy across operating systems while maintaining collaborative relationships with health plans and stakeholders. Key duties include auditing provider records, resolving contract-related discrepancies, and ensuring compliance with organizational policies.
Lead the development of enterprise pharmacy reporting infrastructure and foundational data assets to provide actionable analytical insights. Build and scale reporting layers for Medicare Part D datasets and automate KPI monitoring for finance and operational stakeholders.
Manage and maintain Optum Claims Pricing and Editing software products while performing architectural reviews and strategy development. Responsible for the technical design of projects, debugging large-scale systems, and providing technical support for production issues.
The Care Manager facilitates access to behavioral health and substance use services for youth through integrated service plans. They are responsible for making timely intensity of service determinations and managing emergency response access.
Develop and maintain strong relationships with healthcare providers to drive performance and satisfaction. Support network management strategies, resolve provider disputes, and conduct educational orientation sessions.
Medical Director Utilization Management
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
Lead operational areas of the Utilization Management program, ensuring patient care decisions are medically appropriate and aligned with regulatory guidelines. Collaborate with multidisciplinary teams to develop medical policies and conduct peer-to-peer discussions with providers.
Develop and execute outreach strategies to improve health outcomes and increase member engagement within assigned Michigan territories. Deliver health education, support community programming, and mentor junior Community Health Educators.
Conduct comprehensive investigations into reported or suspected fraud, waste, and abuse across various healthcare products. This includes performing interviews, analyzing billing patterns, and coordinating with law enforcement and public officials.
The role involves interpreting clinical criteria to review and approve prior authorization requests for pharmacy and medical claims. It also requires coordinating with pharmacists and providers while handling inbound and outbound inquiries.
Supervise and coach staff within the Provider Network Operations department to ensure efficiency and compliance with contractual requirements. Oversee provider data maintenance, resolve provider inquiries, and monitor operational compliance with Plan policies.
Lead the end-to-end execution of high-priority Medicaid proposal efforts, ensuring compliant and compelling responses. Coordinate between capture, solution design, and executive leadership to align strategy and manage risks throughout the RFX lifecycle.
The Manager supports corporate strategy, analytics, and insights by developing deliverables for the CEO and Board of Directors. They lead strategy projects, conduct market research, and mentor analysts to identify strategic opportunities.
Lead a team in delivering healthcare data and medical economics analyses to improve costs and operational performance. Partner with cross-functional teams to translate complex data insights into strategic business recommendations.
The Enrollment Business Analyst develops and maintains business requirements, rules, and operational processes for the Enrollment department. This includes documenting processes, conducting root cause reviews, and creating actionable reports for leadership.
Manage the full life cycle of member and provider appeals and grievance cases, including intake, investigation, and documentation. Coordinate with internal departments to ensure timely resolution in compliance with federal, state, and accreditation standards.
Coordinate long-term services and supports for Medicaid participants through face-to-face assessments and participant-centered planning. Manage the delivery of physical, behavioral, and social services while ensuring participants are informed of their rights and options.
Cost of Benefits Solutions Manager
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
The manager identifies COB overpayment and operational process improvement opportunities while leading the development of recovery tools. They serve as the primary technical point of contact for IS issues and manage TPL dashboard reporting and data reconciliations.
The role involves interpreting clinical criteria to review and approve prior authorization requests for pharmacy and medical claims. It also requires coordinating with pharmacists and providers while handling inbound and outbound inquiries.
Medical Director Utilization Management
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
Provides organizational leadership for appeals, utilization review, and quality improvement initiatives to ensure clinically sound services for enrollees. Manages day-to-day operations and collaborates with multidisciplinary teams to optimize behavioral and physical health services.
The analyst conducts research and analysis of regulatory edits to identify and validate overpayment concepts for Medicaid and Medicare lines of business. They are responsible for implementing cost avoidance processes and ensuring payment rules are updated based on federal and state statutes.
Medical Director Utilization Management
Amerihealth Caritas
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Full Time
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3 hours ago
Amerihealth Caritas
Lead the operational areas of the Utilization Management program, ensuring patient care decisions are medically appropriate using national and local criteria. Collaborate with multidisciplinary teams to develop medical policies and analyze utilization trends to improve clinical effectiveness.
Manage and coordinate care for medically fragile members with complex health conditions and behavioral health needs. Serve as the primary point of contact for the care team to develop and monitor personalized plans of care.
Provide front-line customer support by handling inbound telephone inquiries from members, pharmacies, and prescribers. Responsibilities include educating prescribers on formulary processes and assisting members with pharmacy benefit inquiries.
The analyst performs research and creates reports to monitor fraud, waste, and abuse (FWA) cases within assigned lines of business. They are responsible for extracting data from various systems to provide statistical findings and recommendations to management.
The Innovation Manager leads the development and execution of high-impact initiatives to improve care for complex populations and high-need members. This includes managing external partnerships, coordinating cross-functional internal teams, and translating state policy into operational solution models.
Lead the end-to-end execution of Medicaid RFX responses, translating capture strategy into compliant and high-quality proposals. Act as the central integrator across solution design, writing, and production to ensure on-time, error-free submissions.
Lead the operational areas of the Utilization Management program, ensuring patient care decisions are medically appropriate using national and local criteria. Collaborate with multidisciplinary teams to develop medical policies and analyze utilization trends to improve clinical effectiveness.
Process service forms and distribute literature to members while managing provider directories and welcome kits. Research and correct mailing addresses using USPS tools and maintain department production statistics.
