AmeriHealth Caritas Provider Network Analyst in New Castle, Delaware

Provider Network Analyst


AmeriHealth Caritas Delaware is excited to have been chosen as one of the Medicaid managed care plans for the Diamond State Health Plan and Diamond State Health Plan- Plus programs. Backed by a national organization, we have long-term experience serving the Medicaid population in neighboring states. We are committed to delivering health care through innovative services and programs and are looking forward to helping Delaware become an even healthier state.


This position reports to the Manager, Provider Reimbursement in facilitating and investigating cross-departmental issue resolution as they relate to provider claim reimbursement.

The primary purpose of the job is to be responsible for the maintaining current provider data and provider reimbursement set up, and to address provider/state inquiries as it relates to claim payment issues. Responsibilities:

  • Develops the Pricing Agreement Templates (PAT) for all provider reimbursement set up
  • Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, researched and resolved within established SLA timeframes
  • Serves as the subject matter expert in State specific health reimbursement rules and provider billing requirements and as liaison to the Enterprise Operations Configuration Department
  • Maintain a current working knowledge of processing rules, contractual guidelines, state/Plan policy and operational procedures to effectively provide technical expertise and business rules
  • Participate in encounter rejection reconciliation activities
  • Responsible for the analysis of provider reimbursement and updating codes and fee schedules for current reimbursement to providers
  • Participate in Provider Reimbursement medical policy and edit reviews
  • Requests/runs queries to identify root causes of claim denials, incorrect payments and claims that are not correctly submitted for payment
  • Act as the resource to other departments by developing and managing work plans which document the status of key relationship issues and action items for high profile providers
  • Ensures ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits
  • Validate potential recovery claim project activities
  • Maintain tracking system of operational issues, progress, and status
  • Performs other related duties and projects as assigned


  • Bachelors degree or equivalent experience with emphasis in health services administration, information systems, or equivalent experience in medical office administration and/or claims administration, claims experience preferred
  • Two plus years of claims analysis experience in a healthcare environment
  • One to two years managed care or related experience preferred
  • One to two years Medicaid experience preferred
  • Claims processing and Provider data maintenance knowledge required
  • Understanding of and experience related to healthcare claims payment configuration process/systems and its relevance/impact on network operations required
  • Billing and coding experience a plus
  • Strong with MS Excel, Access, Word, MS Access, MSOffice, Pivot Charts, Analytics