AmeriHealth Caritas Director, Plan Operations & Administration in Harrisburg, Pennsylvania

Director, Plan Operations & Administration

Location: Harrisburg, PA

Telecommuter?: No

ID**: 14483

Your career starts now. We’re looking for the next generation of health care leaders.

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 .

Responsibilities:

  • Understand state program contractual and regulatory requirements (benefit and payment rules, data and information submission specifications, performance and service level requirements, etc.) and ensure requirements are met for the plan.

  • Act as a liaison between the state, health plan and enterprise functions.

  • Accountable for all contractual obligations and ensures that both local and corporate resources deliver on all commitments.

  • Act as a second in command to the Executive Director.

  • Ensure that all service levels are met for all functional areas supporting the plan, including corporate, regional, and local functions. Addresses the need for corrective action when any service levels are not met.

  • Oversee the submission of specific information to corporate, based on the plan’s provider contracts, for configuration of the system to support payment of claims. Responsible for ensuring that claim payments, once configuration has been completed, are consistent with the terms of the contract.

  • Responsible for internal operational functions and oversight of corporate functions that support key plan requirements such as claims processing and encounter data submissions and corrections.

  • Maintain up-to-date Policies and Procedures for all local functions, conforming to regulatory requirements.

  • Track State Bulletins to identify changes and operational impacts, communicates them, and marshal local, regional and corporate resources to make necessary system and process changes to meet the requirements.

  • Convene regular operational meetings at the plan to include peers, e.g., provider network management, compliance, community outreach, to facilitate coordination of plan activities.

  • Support the execution, in collaboration with the Regional CFO and CMO, of cost containment initiatives. Responsible for developing action plans and tracking results for operational cost containment initiatives.

  • Proactively identify risks that would impact the Plan’s ability to meet enterprise and local strategic and financial goals and develop strategies to mitigate the risks.

Education/Experience:

  • Bachelor’s Degree.

  • 5-10 years Understanding of Medicare/Medicaid operations -benefit administration.

  • Previous management experience required.

  • Proven experience in navigating relationships in a matrixed organization.

EOE Minorities/Females/Protected Veterans/Disabled