The Care Connector supports daily operations of integrated care and utilization management programs within a contact center environment. They process calls from members and providers to provide educational materials and strategies to increase healthcare adherence.
Amerihealth Caritas
74 Remote Job Openings at Amerihealth Caritas
The Care Connector supports integrated care and utilization management operations within a contact center environment. They process calls from members and providers while providing educational materials to increase healthcare adherence.
Per Diem Medical Director Utilization Management
Amerihealth Caritas
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Full Time
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5 days ago
Amerihealth Caritas
Perform daily medical reviews, appeals, and physician peer reviews while implementing evidence-based practice guidelines. Oversee the quality of clinical care and ensure adherence to contractual and regulatory obligations for health plan members.
The Outcomes Specialist will evaluate member care and support programs by developing models and conducting analytic work. They will collaborate with cross-functional teams to provide data-driven insights and manage multiple large projects.
The Market President provides strategic vision and operational leadership for the Ohio health plan, focusing on growth and member retention. They are responsible for full P&L management and cultivating relationships with regulators, providers, and community stakeholders.
Medical Director Utilization Management
Amerihealth Caritas
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Full Time
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6 days ago
Amerihealth Caritas
Provides organizational leadership for utilization review, appeals, and quality improvement initiatives to ensure clinically sound services for enrollees. Manages day-to-day operations and develops medical policies to optimize the use of physical and behavioral health services.
Manage and coordinate care for members with acute, chronic, and behavioral health conditions, specifically within the Foster Care program. Act as the primary point of contact for the care team to develop and monitor personalized care plans and facilitate transitions of care.
The Care Connector supports integrated care and utilization management operations within a contact center environment. They process calls from members and providers while providing educational materials to increase healthcare adherence.
Provides strategic leadership and operational oversight for the UAT team validating complex Facets configuration changes. Ensures system accuracy and compliance across claims, benefits, and enrollment modules to mitigate operational and financial risks.
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.
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.
Provides strategic legal counsel and regulatory guidance specifically for the Company's Exchange Marketplace business. Partners with cross-functional leaders to interpret laws, assess operational risks, and implement compliant business strategies.
Provide clinical leadership and operational oversight for the Care Management team to ensure effective care coordination and regulatory compliance. Monitor staff performance, manage workflows, and collaborate with stakeholders to improve program outcomes and member satisfaction.
The Instructional Designer creates and updates training materials and experiences to ensure knowledge acquisition for Provider Network Management Associates. This includes blending instructional design methodologies with LMS technology and collaborating with SMEs to deliver blended and e-learning offerings.
The Senior Training Specialist facilitates training and development activities across the organization using adult learning principles and the ADDIE model. They design and implement complex learning strategies across multiple modalities, including virtual and blended learning, to improve organizational performance.
Lead workstreams for the strategy, design, and execution of the strategic investment portfolio to realize value and align with organizational goals. Develop business cases, monitor project financial spend, and create executive-level reports and dashboards for senior leadership.
Senior Director Enterprise Forecast Modeling & Insights
Amerihealth Caritas
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Full Time
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12 days ago
Amerihealth Caritas
The Senior Director is responsible for the design, governance, and continuous advancement of the enterprise forecast architecture and modeling. This role translates forecast outputs into actionable insights for executive leadership while ensuring alignment across actuarial and finance teams.
The Behavioral Health Coordinator acts as a liaison between government agencies and providers to coordinate integrated behavioral healthcare services. Responsibilities include conducting member outreach, maintaining electronic documentation, and fostering collaboration between primary care and behavioral health providers.
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.
Audit and analyze Facets configuration changes to ensure accuracy and completeness of modifications. Build complex queries to identify affected claims and perform post-implementation reviews to validate production migration.
Provides strategic legal counsel and regulatory guidance specifically for the Company's Exchange Marketplace business. Partners with cross-functional leaders to mitigate legal risks and implement compliant business strategies.
The Care Manager II assesses members with complex medical and behavioral needs to develop and monitor individualized care plans. They coordinate physical, behavioral, and social services while collaborating with providers and caregivers to improve health outcomes.
The Care Connector supports daily operations of integrated care and utilization management programs within a contact center environment. They process calls from members and providers to provide educational materials and strategies to increase healthcare adherence.
Manage and coordinate care for members with acute, chronic, and behavioral health conditions, specifically focusing on maternity and maternal health. Act as the primary point of contact for the care team to develop personalized care plans and improve member health outcomes.
The role involves formulating system scope and objectives for FACETS application changes to support health plan benefit and payment structures. The analyst will lead complex projects, automate configuration processes, and provide technical consultancy to service operations.
Facets Business Systems Analyst Sr
Amerihealth Caritas
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Full Time
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13 days ago
Amerihealth Caritas
The role involves serving as a technical consultant to design, test, and implement benefit and payment structure changes within the FACETS application. The analyst will lead complex projects, automate configuration processes, and mentor junior analysts to ensure system reliability.
Manage the technical team responsible for migrating and integrating FACETS configuration changes across all lines of business. Serve as a technical consultant for health plans and mentor junior Business System Analysts.
Lead financial governance and value realization for strategic investments across the enterprise portfolio. Partner with finance and business leaders to build business cases, track performance, and report insights to senior leadership.
Coordinate and track incoming and outgoing correspondence, faxes, and authorizations for medical service reviews. Interact with facilities, vendors, and providers to facilitate the prompt receipt of information and records.
The analyst is responsible for the end-to-end administration, reconciliation, and processing of commission payments for ACA and Medicare products. This includes resolving payment discrepancies, calculating monthly payouts, and partnering with Finance and Sales to improve processes.
Lead and coordinate clinical quality reviews of member concerns and medical records using standards of care. Support accreditation, HEDIS activities, and Quality Assessment and Performance Improvement (QAPI) committee processes.
Oversee payment integrity strategy and performance across multiple lines of business using AI, ML, and NLP-based automation. Lead provider engagement strategies and manage the Payment Integrity Support Desk to ensure operational efficiency and regulatory compliance.
Serve as the primary liaison between the health plan and healthcare providers to ensure contract compliance and high provider satisfaction. Responsibilities include recruiting qualified providers, monitoring network adequacy, and analyzing performance metrics to implement improvement strategies.
The Clinical Auditor coordinates quality audits of clinical staff and delegated provider groups to ensure compliance with NCQA and state regulations. They identify trends, conduct root cause analyses, and develop corrective action plans to improve clinical performance.
Medical Director Utilization Management
Amerihealth Caritas
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Full Time
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21 days ago
Amerihealth Caritas
Lead operational areas of the Utilization Management program, ensuring patient care decisions are medically appropriate based on national and local criteria. Collaborate with multidisciplinary teams to develop medical policies and analyze utilization trends to improve clinical effectiveness.
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.
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.
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.
Family Medicine Medical Director Utilization Management
Amerihealth Caritas
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Full Time
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21 days 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.
Vice President Provider Network Management
Amerihealth Caritas
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Full Time
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21 days 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.
MDM / ERDM Business Systems Analyst Senior
Amerihealth Caritas
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Full Time
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21 days 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.
Director Quality and HEDIS Data Strategy
Amerihealth Caritas
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Full Time
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21 days 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.
Network Contractor Provider Network Management
Amerihealth Caritas
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Full Time
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21 days 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.
Payment Integrity Client & Vendor Management Manager
Amerihealth Caritas
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Full Time
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21 days 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.
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.
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.
Appeals & Grievance Case Resolution Specialist
Amerihealth Caritas
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Full Time
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21 days 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.
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.
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.
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 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.
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.
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.
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.
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.
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.
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.
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.
Medical Director Utilization Management
Amerihealth Caritas
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Full Time
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21 days 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 maintain strong relationships with healthcare providers to drive performance and satisfaction. Support network management strategies, resolve provider disputes, and conduct educational orientation sessions.
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 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.
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.
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 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.
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.
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.
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.
Medical Director Utilization Management
Amerihealth Caritas
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Full Time
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21 days 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.
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.
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.
