AmeriHealth Caritas Provider Network Analyst - Medicare in Philadelphia, Pennsylvania

Provider Network Analyst - Medicare

Location: Philadelphia, PA

Telecommuter?: No

ID**: 14391

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:

This position will have direct responsibility for monitoring and ensuring timely update of all CMS and State Fee Schedules; creation of Compensation Grids in accordance to contract terms; Provider Data analysis, reconciliation and monitoring of: HSD Tables, Directories, Maximus files and Provider Quarterly mailings. In addition, the position will support:

  • Ongoing analysis of provider data to assure quality and adherence to defined procedures.

  • Data discrepancy reporting and resolution.

  • Provider Rosters and Medicare Corporate Provider return mail.

  • Create and maintain Medicare Provider Contract, Configuration and issue tracking and status reporting.

  • Translation of CMS Medicare Provider Data requirements into reports of these functions to ensure performance standards meet all CMS Directory, HSD Table, Claims and Audit requirements as well as applicable State and Contractual requirements.

  • Collaborate with Provider Network Management, Provider Data Management, Provider Data Integrity, Claims and any/all other Departments.

  • Development of department workflows, policies and procedures as well as training material, recurring and complex ad-hoc reports and data sets.

  • This position will also demonstrate proficiency with trending and performance analysis, recognizing patterns and possible variables that impact performance.

  • Identification of operational gaps, risks and issues, opportunities for efficiencies and strategies for process improvement.

  • Development of short and long term solutions, monitoring plans and mechanisms; implementation and UAT for change management and process improvement.

  • Ability to develop and understand business process flows and impact to performance results. Elaborate findings, insights and communicate such to management, internal and external customers.

  • Express status of performance through summaries, including changes in performance and impact to performance standards.

  • Requires extensive knowledge of CMS Medicare Advantage industry, keeping abreast of changes in CMS requirements impacting Medicare Provider operations functions and performance.

  • Able to understand business process flows and impact to performance results.

  • Elaborate findings, insights and communicate such to management, internal and external customers.

  • Express status of performance through summaries, including changes in performance and impact to performance standards.

Education/Experience:

  • 5 + years' claims processing, configuration and Medicare.

  • Bachelor’s Degree or equivalent experience.

  • CMS Medicare technical experience and understanding of regulatory requirements.

  • Microsoft Office, FACETS, SQL, SAS, , Crystal Reports, Data warehouse ad hoc queries.

  • Must haves Medicare and FACETS experience in order to apply .

EOE Minorities/Females/Protected Veterans/Disabled