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. Ameri
Health 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, Ameri
Health 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 .
NO EXCEPTIONS PLEASE. MUST RESIDE IN/NEAR DELAWARE
The AE II is responsible for building, nurturing and maintaining positive working relationships between Plan and its contracted providers. Assigned provider accounts may include single or multiple practices in single or multiple locations, integrated delivery systems or other provider organizations. AE II maintains in depth understanding of Plan’s contracts and provider performance and needs, identifying, developing and conducting relevant and tailored provider orientation sessions, making educational visits and working to resolve provider issues.
Responsible for monitoring and managing provider network by assuring appropriate access to services throughout the Plan’s territory in keeping w/ State and Federal contact mandates for all products. Identifies, contacts and actively solicits qualified providers to participate in Plan at new and existing service areas and products, assuring financial integrity of the Plan is maintained and contract management requirements are adhered to, including language, terms and reimbursement requirements.
Maintains complete understanding of Plan reports and metrics and uses them to evaluate the performance of assigned providers/practices/facilities, determining, communicating and implementing plans for providers to improve performance and measuring ongoing performance. Uses data to develop and implement methods to improve relationship. Assists in corrective actions required up to and including termination, following Plan policies and procedures. Supports the Quality Management department with the credentialing and re-credentialing processes, investigation of member complains and any potential quality issues.
Maintains a functional working knowledge of Facets, including the provider database and routinely relays information about additions, deletions or corrections to the Provider Maintenance Department. Maintains and delivers accurate, timely activity and metric reports as required. Identifies and maintains strong partnerships with appropriate internal resources and stakeholders.
- Bachelor’s Degree or equivalent experience.
- Minimum of 5 years of managed health care experience with demonstrated skill and proficiency with software applications capable of provider-specific reports, such as network adequacy, payment rules, provider services and directory.
- Required Claims processing and Provider Data Maintenance knowledge.
- Understanding of and experience related to healthcare claims payment configuration process/systems and its relevance/impact on network operations required. This would include experience with Facets or similar applications and their supporting database schema and structure.
- Formal training or equivalent experience in the effective use of reporting and querying software such as MS Excel, MS Access, Crystal Reports and/or SQL required.
- Advanced experience with sophisticated databases. Full competence in report preparation, layout and design.
- Ability to plan, organize and handle multiple tasks.
- In depth expertise in data analysis and data mining. Superior analytical skills.
Clipped from: https://www.learn4good.com/jobs/online_remote/healthcare/587114639/e/