The Pharmacy Director oversees clinical and operational aspects of the pharmacy benefit, including PBM management and regulatory compliance. They are responsible for implementing process improvements, monitoring pharmacy trends, and supporting quality measures to ensure cost-effective care for LTSS members.
Amerihealth Caritas
80 Remote Job Openings at Amerihealth Caritas
Provider Network Account Executive I
Amerihealth Caritas
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Full Time
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3 days ago
Amerihealth Caritas
The Account Executive develops and maintains strong relationships with healthcare providers to drive performance and ensure provider satisfaction. They are responsible for provider education, resolving disputes, and supporting network development strategies within assigned regions.
The Senior Proposal Quality and Editing Specialist performs critical quality and copy editing reviews for managed care proposals while managing project timelines and internal process updates. They collaborate with the Copy Editing Manager to ensure team alignment, provide research support, and act as a subject matter expert for language and style standards.
Manage the full recruitment lifecycle for complex roles, including sourcing, engaging, and onboarding top talent. Serve as a consultative partner to hiring managers by providing labor market insights and developing strategic recruitment plans.
The Senior Data Analyst serves as a subject matter expert responsible for training new hires, overseeing provider data processing, and ensuring compliance within Provider Network Operations. They also develop process improvements, manage complex datasets, and maintain strong relationships with internal and external stakeholders.
The administrator screens and processes member and provider grievances related to Medicare and Medicaid programs. They also support investigation specialists by managing case documentation, generating correspondence, and monitoring work queues.
The Manager of Product Management leads a team of product managers to deliver clinically-driven population health products across a multistate Medicaid managed care organization. This role balances coaching talent, ensuring delivery quality, and partnering with senior leadership on portfolio strategy and stakeholder alignment.
The Care Connector supports integrated care management interventions by processing calls from members and providers. They also provide educational materials to members and implement strategies to increase healthcare adherence and reduce barriers to care.
The Community Health Navigator engages members through outreach and home visits to address social determinants of health and improve access to care. They collaborate with internal teams and community organizations to coordinate care and provide education on benefits and preventive health programs.
The Community Educator promotes health programs through site visits, community events, and educational workshops. They are responsible for identifying potential Medicaid candidates, assisting with enrollment, and maintaining professional relationships with community agencies.
Medical Economics Consultant Senior
Amerihealth Caritas
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Full Time
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5 days ago
Amerihealth Caritas
The consultant is responsible for leading the development of market trend analytics and enterprise-wide trends to support the Total Cost of Care review process. They will communicate insights to leadership and coordinate with business teams to develop high-value opportunities for savings and revenue.
The Behavioral Health Coordinator acts as a liaison between regulatory agencies, healthcare providers, and members to facilitate cost-effective and quality care. They are responsible for identifying, assessing, and coordinating services while monitoring and resolving issues related to member access and care delivery.
Medical Director Utilization Management
Amerihealth Caritas
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Full Time
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5 days ago
Amerihealth Caritas
The Medical Director leads the Utilization Management program, ensuring clinical appropriateness of care and adherence to medical policies. They also collaborate with multidisciplinary teams to analyze utilization trends and facilitate peer-to-peer discussions with providers.
The Senior Data & Reporting Analyst designs and develops reporting systems while managing project plans to ensure deliverables meet business and customer needs. They are responsible for analyzing clinical and utilization data to provide actionable recommendations that improve system efficiency and care outcomes.
The Service Coordinator identifies and manages the long-term care needs of Medicaid participants through face-to-face assessments and ongoing coordination. They lead the participant-centered planning process and ensure compliance with Community Health Choices requirements.
The Corporate Director of Network Strategy leads the development and management of an enterprise-wide provider network strategy to optimize total network value. This role collaborates with cross-functional leadership to deploy programmatic solutions, manage operational reporting, and oversee provider experience teams.
The Account Executive is responsible for identifying, recruiting, and contracting healthcare providers to build high-performing networks that meet CMS and state requirements. They also manage provider relationships, ensure accurate credentialing, and contribute to strategic business planning for network expansion.
Senior Medical Director Value Based Care
Amerihealth Caritas
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Full Time
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7 days ago
Amerihealth Caritas
The Senior Medical Director leads enterprise strategies to optimize healthcare value, improve affordability, and reduce medical expenses while maintaining high-quality outcomes. They provide executive oversight for clinical policy governance, payment integrity, vendor performance, and value-based contracting initiatives.
Corporate Director of Accreditation and Compliance
Amerihealth Caritas
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Full Time
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7 days ago
Amerihealth Caritas
The Corporate Director of Accreditation and Compliance provides strategic leadership for accreditation readiness, regulatory compliance, and quality governance across the organization. This role oversees audit preparation, risk mitigation, and cross-functional partnerships to ensure adherence to federal, state, and contractual requirements.
The Senior Medical Director oversees clinical care quality, utilization management, and behavioral health programs while ensuring adherence to regulatory and contractual requirements. They lead a team of medical directors, manage medical policy development, and drive continuous quality improvement initiatives.
The analyst is responsible for maintaining provider data, managing reimbursement setups, and resolving claim payment issues. They also oversee payment integrity audits, state policy analysis, and encounter error reconciliation.
The Care Manager assesses, plans, and coordinates care for members to achieve optimal health outcomes while serving as a single point of contact. They are responsible for creating person-centered care plans, facilitating services, and documenting progress within the electronic medical record system.
The investigator conducts comprehensive investigations into suspected fraud, waste, and abuse across various healthcare products. They are responsible for interviewing witnesses, analyzing billing patterns, and preparing detailed investigative reports for legal and regulatory compliance.
The role involves overseeing provider data, reimbursement rules, and operational workflows to ensure contractual compliance across various health products. The individual will serve as a subject matter expert, managing provider escalations and collaborating with internal departments to optimize claims processing and network reporting.
Manage and support the Salesforce development and delivery team while overseeing the technical aspects of Member CRM projects. Lead and mentor developers to ensure successful implementation of complex system integrations and Salesforce features.
The Community Educator promotes health programs through site visits and community events while identifying and enrolling potential Medicaid candidates. They are responsible for building relationships with community agencies and providing educational presentations to members and organizations.
Part Time Behavioral Health Care Manager
Amerihealth Caritas
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Full Time
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11 days ago
Amerihealth Caritas
The Behavioral Health Care Manager oversees clinical department functions including triage, care coordination, and utilization management for youth services. They facilitate access to therapeutic resources and ensure integrated service plans are maintained to support youth in their homes and communities.
The manager will oversee departmental integrity, data management, and compliance with Community HealthChoices Long-Term Service and Support requirements. They are responsible for developing workflows, conducting audits, and coordinating outreach and training for staff and stakeholders.
The manager will oversee departmental integrity, data management, and compliance with Community HealthChoices Long-Term Service and Support requirements. They are responsible for developing workflows, training staff, and managing transitional services while maintaining key performance metrics.
The supervisor oversees daily operations of the Case Management unit, providing clinical direction and guidance to staff. They monitor team performance, ensure regulatory compliance, and support process improvement initiatives.
The Director of Medical Economics leads the planning and execution of data policies and reporting to support the Total Cost of Care program. They are responsible for managing teams, synthesizing data for actionable insights, and communicating findings to business partners to drive strategic goals.
The Instructional Designer will develop and update training materials and experiences to ensure effective knowledge acquisition for AmeriHealth associates. They will collaborate with SMEs and trainers to deliver high-quality virtual and live training while managing LMS setups and reporting outcomes.
The Personal Care Connector handles inbound and outbound calls to support Medicare members and providers within a call center environment. They are responsible for identifying care gaps, educating members on benefits, and facilitating access to healthcare resources.
Provide front-line customer support by handling inbound inquiries from members, pharmacies, and prescribers. Educate stakeholders on formulary processes and ensure accurate documentation of customer data.
The role involves interpreting clinical criteria to review and approve prior authorization requests for pharmacy and medical claims. It also requires handling inbound and outbound calls to gather information and assisting with appeals processing.
The Care Manager assesses members with complex medical and behavioral needs to develop and implement individualized care plans. They coordinate physical, behavioral, and social services while collaborating with providers and caregivers to improve health outcomes.
Technical Analytics Product Manager
Amerihealth Caritas
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Full Time
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18 days ago
Amerihealth Caritas
The role involves driving the development of the analytics product portfolio by collaborating with cross-functional teams to define requirements and technical specifications. The manager will also monitor performance metrics and conduct UAT to optimize product functionality and customer value.
Lead the strategic direction and operational execution of care coordination and population health programs to ensure high-quality, member-centered clinical services. Oversee multidisciplinary teams and ensure compliance with state and federal regulations, specifically the MDHHS contract.
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 performance metrics like HEDIS and CAHPS.
Develop and execute outreach strategies to improve health outcomes and member engagement within assigned Michigan territories. Deliver health education, manage community-based programming, and mentor junior Community Health Educators.
The Care Manager coordinates comprehensive care for members with complex medical, behavioral, and social needs, specifically focusing on the maternity population. Responsibilities include conducting person-centered assessments, developing individualized care plans, and collaborating with providers to improve health outcomes.
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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25 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.
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.
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.
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.
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 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.
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.
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.
Facets Business Systems Analyst Sr
Amerihealth Caritas
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Full Time
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a month 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.
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.
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.
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.
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.
MDM / ERDM Business Systems Analyst Senior
Amerihealth Caritas
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Full Time
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a month 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.
Vice President Provider Network Management
Amerihealth Caritas
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Full Time
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a month 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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a month 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.
Network Contractor Provider Network Management
Amerihealth Caritas
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Full Time
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a month 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.
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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a month 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.
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.
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.
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.
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 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.
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.
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.
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.
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 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.
