AmeriHealth Caritas Medicare Program Specialist in Philadelphia, Pennsylvania

Medicare Program Specialist

Location: Philadelphia, PA

Telecommuter?: No

ID**: 16351

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 .

The Medicare Program Specialist serves as a subject matter expert within the Company regarding Medicare rules and works with individual departments to research, identify and address areas of vulnerability related to regulatory or accreditation (URAC/NCQA) compliance. This includes tracking, reviewing and analyzing policies, regulations and compliance requirements that could impact PerformRx's products; responding to internal requests for regulatory interpretation and guidance; ensuring that PerformRx participates in all regulatory and sub-regulatory comment periods for PBM-specific guidance, including the Star Ratings.

  • Read, interpret, summarize, and assess the impact on business operations of Medicare and or accrediting body regulations, guidance, and communications.

  • Write client bulletins, policies, desktop procedures, and corrective action plan responses.

  • Support the administration of internal and external audits, CMS Complaint Tracking Module issues, the annual Part D application process, reporting requirements, and data validation audits.

  • Support the testing and validation of the Medicare Prescription Drug Plan Finder, formulary, marketing materials, and the PerformRx client portal

  • Provide training and presentations to internal departments and PerformRx customers on an s needed basis Document and maintain project plans and status reports as related to the annual Part D implementation process, audits, and other ad hoc initiatives as needed.

  • Coordinate the oversight of PerformRx departments and subcontracted vendors to ensure compliance with Medicare and accrediting body requirements.

  • Support the transmittal of information and documentation on behalf of PerformRx clients to accrediting agencies as required.

  • Acts as the regulatory lead on new and continuing client implementation activities.

  • Provide contract administration support as it relates to the identification of accrediting body regulations that affect contract terms between PerformRx and its clients and subcontracted vendors.


  • Bachelor’s Degree or 4+years’ experience in regulatory, privacy, and/or legislative policy and processes, preferably in a managed health care setting.

  • 1-3 years' Managed Care or pharmacy including URAC, NCQA, and/or Star Ratings experience.

  • 3-5 years' Professional work experience in regulatory, privacy, and/or legislative policy and processes, preferably in a managed health care setting.

  • Must possess strong research and analytical skills, as well as excellent written & oral communications skills.

  • Demonstrated competency in research and tracking of health policy and regulations.

  • Possesses ability to analyze and interpret policy, ability to identify relevance and potential to PerformRx.

  • Ability to deliver information accurately in a fast-paced environment with insight and perspective.

  • Proficiency with MS Office Suite and Internet required.

  • PBM, Medicare (Part D), Health Insurance Marketplace (Exchanges) preferred.

EOE Minorities/Females/Protected Veterans/Disabled