AmeriHealth Caritas Enterprise Operations Solutions Analyst, Senior in Philadelphia, Pennsylvania
Enterprise Operations Solutions Analyst, Senior
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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 www.amerihealthcaritas.com.
The primary purpose of the Senior Enterprise Operations Solutions Analyst is to function as the lead subject matter expert and analyst on all research and analysis of provider claim issues and escalated complaints that are referred state agencies, plans, providers, or other departments within AmeriHealth Caritas. This position reports directly to the Manager, Enterprise Operations Solutions.
- Responsible for supporting business processes and practices for all Lines of Business.
- Functions as the lead for all research and analysis of provider claim payment issues.
- Identify and present root causes and recommended correction for complex operational claim payment problems that may result in policy changes, provider education, system configuration changes, etc. This includes developing and presenting recommendations based on analyses of large data sets and providers guidance for real time resolution of issues.
- Develop and maintain tracking mechanisms to identify and address provider claim issues and escalated complaints through remediation.
- Analyze trends related to claim experience to proactively identify potential issues before they arise.
- Inform and influences claims process for new initiatives or services to be offered.
- Maintains a current working knowledge of processing rules, contractual guidelines, Plan policy and operational procedures to effectively provide technical expertise.
- Develop business models and documentation to support business decisions, workflows, and processes.
- Focus on technology and business issues as well as communicate appropriately with both technology and business experts.
- Utilize various technology applications to track, trend, store information related to claims processing, provider maintenance, member eligibility, etc.(MS Access, Excel/Pivot charts, Word, SQL).
- Ability to communicate and represent the Operations Business Integration Team throughout the Enterprise, as well as presenting and engaging with key providers and State Agencies as needed.
- Responsible for oversight and facilitating Operational Meetings as needed.
- Act as a liaison and participate in defining, conveying, and documenting business requirements to solve complex claims issues, business issues or problems.
- Build business cases that will enable business and technology change based on requirements.
- Provide guidance and assistance to Operations Business Integration Specialist.
- 3-5 years of healthcare experience with claims, encounters and/or research and analysis.
- Bachelor's Degree or equivalent experience.
- Extensive claims experience required.
- Strong with MS Excel, Access, Word SQL, MS Access, MS Office, Pivot Charts, Analytics
- Billing and coding experience a plus.
- Ability to establish and maintain effective relationships with all levels of the organization.
- Strong ability to multi-task and address various lines of business in regard to status of efforts, business responsibilities.
- Ability to communicate effectively with all levels of associates up through executive management.
- May need to support critical efforts outside of normal business hours dependent on department need.
- Some travel may be needed for business meetings.
EOE Minorities/Females/Protected Veterans/Disabled